Systematic Review of Treatment Effectiveness and Outcome Measures for Enthesitis in Psoriatic Arthritis

Abstract

Enthesitis is a characteristic feature of psoriatic arthritis (PsA) and is important in disease pathogenesis and classification. Use of clinical outcome measures for enthesitis is heterogeneous, and only 1 measure has been specifically developed and validated in PsA. Ultrasound and magnetic resonance imaging assessments of enthesitis may have advantages over clinical examination but are insufficiently studied. As part of an update of treatment recommendations by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), we performed a systematic literature review and identified randomized controlled trials with enthesitis outcomes in PsA. For each treatment agent we calculated treatment effect sizes (where applicable) and graded the level of evidence.

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis

“…Physiotherapy is also often prescribed, although formal studies of efficacy have not been published. In one study with defined enthesitis end points and placebo controls, SSZ was not effective , and no published data support the efficacy of other DMARDs in placebo‐controlled studies . There is high‐quality evidence of the effectiveness of TNFi and ustekinumab .…”

“…In one study with defined enthesitis end points and placebo controls, SSZ was not effective , and no published data support the efficacy of other DMARDs in placebo‐controlled studies . There is high‐quality evidence of the effectiveness of TNFi and ustekinumab . Data on the efficacy of PDE‐4i and secukinumab for enthesitis in PsA are published in abstract form only.…”

European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update

“…In this patient population, no data-driven definition of ‘active’ disease (relative to enthesitis/dactylitis) exists and the Task Force considered at least one active localisation as active disease, taking into account quality of life consequences as most relevant in these patients. In these patients, after failure of local or non-specific anti-inflammatory therapy, bDMARDs may be applied even if no csDMARDs have been tried, since the latter have not been proven efficacious in treating these aspects of PsA, especially enthesitis 94 95. The experts felt the data did not allow a definitive primary choice between a TNFi or bDMARDs targeting IL-12/23 or IL-17 pathways, since there are no head-to-head comparisons and based on the available data all these agents appear to have similar efficacy on enthesitis and dactylitis.…”

Prevalence of minimal disease activity in Australian patients with Psoriatic Arthritis: Assessing the outcome of national funding criteria for biologic disease‐modifying antirheumatic drug prescribing

“…The prevalence of enthesitis in our PsA cohort is similar to that of others, and having any enthesitis was twice as likely among those not on a bDMARD. Enthesitis is generally associated with worse function and quality of life; however, there is very little evidence to support the use of any therapies other than bDMARDs and apremilast for enthesitis in PsA . Non‐steroidal anti‐inflammatory drugs, sulfasalazine, methotrexate, leflunomide and lesional corticosteroid injections are either ineffective or inadequately studied …”