With an expanding number of biological therapies now available, the treatment landscape has become more complex, and clinicians look for guidance in selecting the right treatments. A treat-to-target (T2T) approach is recommended as an effective strategy for PsA.

Treatment recommendations, or clinical practice guidelines, offer physicians the best evidence on which to base their clinical decisions so that they can achieve optimal outcomes for their patients. But developing guidelines for psoriatic arthritis (PsA) has been difficult due to the heterogeneous nature of the disease and the introduction of several first-in-class therapies during the past decade. 

Treat-to-target approach

The T2T approach is a concept that expanded from the realms of diabetes and heart disease to rheumatoid arthritis and other inflammatory diseases. Clinical trial evidence has shown that tight control of T2T can help patients with PsA as well.

The goal of T2T is to achieve remission or low-disease activity (ie, few signs of disease), by adjusting therapy accordingly.

With T2T, monitoring can be done monthly or less frequently (every 3 or 6 months). At each visit, the patient is evaluated to see whether they have achieved their goal. If not, there are several options: Increase the medication dose, add a new drug, or switch drug classes. The process proceeds in a stepwise fashion, with increasingly aggressive therapies utilised until remission or low-disease activity, is attained.

The patient evaluation for PsA needs to be comprehensive because PsA has at least five distinct domains: joints, spine, skin/nail disease, dactylitis (a sausage-like swelling of the fingers/toes), and enthesitis (inflammation located where tendons and ligaments attach to bone).

All domains must be taken into account, although most patients don’t have symptoms in every domain. Little correlation exists between improvement in one domain of PsA and others.

PsA guidelines recommend T2T

The Arthritis Foundation acknowledges that T2T has not been the standard of care in PsA, as it is in RA, but guidelines from the American College of Rheumatology now recommend T2T for psoriatic arthritis, too.

Several organisations have published guidelines for PsA. In addition to the American College of Rheumatology (ACR)/National Psoriasis Foundation (NPF), these include the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the European Alliance of Associations for Rheumatology (EULAR). 

All three organisations recommend a T2T approach.

“Psoriatic arthritis can be more complicated than RA.”

-Arthritis Foundation

A major treatment difference

In a review article published in Rheumatology, North American researchers compared and contrasted guidance from these organisations.

According to the authors, although the guidance from the three organisations differs in terms of drug classification, drugs included at the time of publication, and terminology used, the treatment recommendations themselves are fairly uniform, with one exception: the use of a TNF inhibitor (TNFi). Unlike GRAPPA and EULAR, the ACR/NPF recommends selecting a TNFi when actively treating treatment-naïve PsA patients. 

In part, here’s what the ACR/NPF recommendation reads. Note that this is a conditional recommendation based on low- or very-low-quality evidence.

“In treatment-naive patients with active PsA, a TNFi biologic agent is recommended over an OSM [oral small molecule] as a first-line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease.” 

Shared decision-making advised

For a T2T approach to work, the Arthritis Foundation advises that patient preferences be discussed and considered, as part of shared decision-making. During patient discussions, the patient’s preference for an oral vs injectable drug should be assessed, as well as any contraindications to a TNFi.

Weighing the guidelines

When determining which treatment approach is best per guidelines and recommendations, there may be no one right choice, say the experts.

According to the Rheumatology authors, “There is no one best guideline recommended for all clinicians.” They explain that GRAPPA was designed for international application and has more information on skin and nail disease management and that US and European rheumatologists may benefit from consulting the ACR/NPF and EULAR guidelines, respectively, which take into account local health economies.  

This story is contributed by Naveed Saleh and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.