Aiming for Remission in Psoriatic Arthritis

Anna R Moverley, Laura C Coates, Philip S Helliwell

Int J Clin Rheumatol. 2014;9(2):147-153.

Ultrasound Data

Although clinical remission is a laudable goal, experience in rheumatoid arthritis has indicated that even though clinical low disease activity may have been achieved, subclinical synovitis, demonstrated by ultrasound, may persist and may explain subsequent structural progression.^[46] Therefore, it is clear, at least for rheumatoid arthritis, that even in states of clinical low disease persistent synovitis may occur. That this also occurs in PsA is suggested by a study of subclinical disease in early cases, where 87% of patients had at least one joint that demonstrated subclinical synovitis on ultrasound examination.^[47] The same group were, however, not able to show significant levels of subclinical enthesitis in an early cohort of patients.^[48] In fact, in this study, clinical enthesitis was found more often than evidence of enthesitis on ultrasound.

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Table 1. Criteria for minimal disease activity.
Literature search	Remission (n)	Low/minimal disease activity (n)
Hits	477	315
Duplicates	53	40
Not psoriatic arthritis	141	138
Paper not available for review	6	1
Not relevant to remission or review paper only	277	132
Remaining papers for review	6	4

Table 2. Relevant articles from literature search.
Study (year)	Definition	Achieving target (%)	Factors predicting target achievement	Ref.
Cantini et al. (2008)	Absence of joint disease, entheseal disease, dactylitis	24 at 12 months	More frequent in those on anti-TNF	[35]
Lindqvist et al. (2008)	Absence of joint activity, normal inflammatory markers	17 at 6 months	Oligoarticular disease, physician VAS, nail disease	[37]
Gladman et al.(2001)	Absence of joint activity on three consecutive visits	17.6 lasted 2.6 years	Males, fewer joints, lower HAQ	[38]
Saad et al. (2010)	DAS28 rheumatoid arthritis remission criteria	36.1 at 12 months after TNF	Younger age, male, lower inflammatory markers, lower HAQ	[39]
Atteno et al. (2010)	Remission: absence of joint activity MDA: no SJC, <2 TJC, HAQ <0.5	0 42 at 12 months	NA NA	[40]
Coates et al. (2010)	Development of MDA – composite measure of joints, skin, entheses, PROMs	NA	NA	[34]
Coatesand Helliwell (2010)	MDA	34	Oligoarticular disease, low inflammatory markers	[41]
Coates and Helliwell (2010)	MDA	48–52	NA	[36]
Lie et al. (2010)	DAS28 rheumatoid arthritis remission DAS28 rheumatoid arthritis low disease activity	24 at 6 months 42 at 6 months	NA NA	[42]

DAS28: Disease Activity Score for 28 joints; HAQ: Health assessment questionnaire; MDA: Minimal disease activity; NA: Not applicable; SJC: Swollen joint count; TJC: Tender joint count; VAS: Visual analog scale.

Box 1. Results of search strategy for articles on remission in psoriatic arthritis.
Five of seven criteria must be fulfilled: Tender joint count ≤1 Swollen joint count ≤1 Psoriasis Area and Severity Index ≤1 or body surface area ≤3% Patient pain visual analog scale ≤15 mm Patient global activity visual analog scale ≤20 mm Health assessment questionnaire ≤0.5 Tender entheseal points ≤1

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Executive Summary

Introduction to psoriatic arthritis & disease assessment

Psoriatic arthritis is not a benign disease, but demonstrates progressive functional loss and increased morbidity and mortality.
Achieving remission may improve these outcomes.

Natural history of psoriatic arthritis

There are inconsistencies in the literature about the natural history of the condition, which may reflect true differences, but which may also be methodological.
The majority of patients have progressive radiological changes and loss of function.
A subset of patients have an aggressive form of the disease known as arthritis mutilans, which results in accelerated joint destruction and deformity.

Outcome measures & definitions of remission

Outcome measures in psoriatic arthritis are still in development.
Composite measures consider all aspects of the disease including skin, joints, entheses and dactylitis.
Composite measures may take the form of responder indices, disease activity measures or both, and provide numerical definitions of remission.
Definitions of remission vary from pure articular definitions to multidimensional, incorporating several aspects of the disease.

Treat to target in psoriatic arthritis: what is the evidence?

The concept of treat to target in psoriatic arthritis is only just emerging, as both the target and the treatment have only recently been defined.
Recent evidence from a randomized controlled trial of a treat to target strategy has shown improved outcomes.

Ultrasound data: are clinical definitions of remission supported by imaging data?

As in rheumatoid arthritis, clinical definitions of remission are not supported by imaging.
In particular, synovial inflammation may be present in the absence of clinical evidence.

Remission & treatment withdrawal: can patients in remission have their treatment successfully withdrawn?

Early studies suggested that treatment withdrawal for patients in remission was more successful than for patients with rheumatoid arthritis.
More recent evidence indicates that the majority of patients in low disease activity who have their treatment stopped will relapse.
If treatment is restarted then disease control is once more achievable.

Conclusion

Low disease activity is an achievable target in psoriatic arthritis.
It is not sufficient to measure only the articular involvement in this complex heterogeneous disease, but to define remission, and low disease activity in terms of all the major manifestations of this disorder.

Future perspective

Future developments in treatment strategies and treatment targets will refine treatment algorithms in this disease.
Studies in development will help determine biomarkers for the development and control of this complex disorder.

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Aiming for Remission in Psoriatic Arthritis

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