Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force

Abstract

Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field.

Minimal Disease Activity as a Treatment Target in Psoriatic Arthritis: A Review of the Literature

“…As remission by its most stringent definition may be difficult to attain in many patients, minimal or low disease activity has also been proposed as an alternative target for treatment 6 .…”

“…Clinical remission or inactive disease, defined as "the absence of clinical and laboratory evidence of significant inflammatory disease activity," is proposed as the major treatment target according to the T2T recommendations 6 . As remission by its most stringent definition may be difficult to attain in many patients, minimal or low disease activity has also been proposed as an alternative target for treatment 6 .…”

“…Treating to target necessitates defining a quantifiable target; in PsA, this target is recognized as remission both by the international T2T task force and by the recently updated European League Against Rheumatism treatment recommendations 2,6 . Although the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) recommendations do not specifically recommend a treatment target, they do agree that…”

Challenges and Advances in Targeting Remission in Axial Spondyloarthritis

“…Consequently, targeting clinical remission/inactive disease is now a major treatment goal as outlined in current treat-to-target recommendations 1,2 . In March 2016, the current status of treating to target and aiming for remission in axSpA was reviewed by 7 expert rheumatologists and 1 patient representative at an industry-sponsored roundtable discussion.…”

“…The Journal on March 24, 2019 -Published by www.jrheum.org Downloaded from composite measures for axSpA assessment 1,2 . NSAID have shown some positive effects on spinal radiographic progression, which were more prominent in patients with increased CRP levels 28,31 .…”