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A Closer Look at Psoriatic Arthritis Outcome Measures and Disease Control

FEBRUARY 11, 2022

I. Measuring disease activity in psoriatic arthritis (PsA), a disease with heterogeneous manifestations, is important but challenging.

PsA is a disease that has a diverse presentation and course. According to the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), PsA is characterized by 6 clinical domains that are the main focus for treatment and monitoring disease activity.1

 

 aArrows from top to bottom indicate joint resorption, ankylosis, and erosion, respectively.
bArrows show enthesophytes at the plantar fascia and Achilles’ tendon insertions.
cParamarginal syndesmophyte bridging the fourth and fifth lumbar vertebrae. 

 

Based on GRAPPA, the ultimate goals of therapy for all patients with PsA are1:

1. Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071.
2. Ritchlin CT, et al. N Engl J Med. 2017;376(10):957-970.
3. Langley RGB, et al. Ann Rheum Dis. 2005;64 suppl 2(suppl 2):ii18-ii23; discussion ii24-ii25.
4. Yamamoto T. Open Access Rheumatol. 2015;7:55-62.
5. Dogra A, et al. Indian J Dermatol. 2014;59(4):319-333.

 

Numerous composite outcome measures have been developed by GRAPPA and endorsed by the Outcome Measures in Rheumatology (OMERACT) group that evaluate disease activity in these domains.1 Composite measures can vary considerably in terms of the specific disease domains they address and can focus either on a single domain (unidimensional) or multiple domains (multidimensional).1,2

ACR=American College of Rheumatology; BSA=body surface area; CDAI=Clinical Disease Activity Index; cDAPSA=clinical DAPSA; CPDAI=Composite Psoriatic Disease Activity Index; DAPSA=Disease Activity in Psoriatic Arthritis; DAS28=disease activity score for 28 joints; GRACE=GRAPPA Composite Exercise; LDI=Leeds Dactylitis Instrument; LEI=Leeds Enthesitis Index; MDA=minimal disease activity; mNAPSI=modified NAPSI; NAPSI=Nail Psoriasis Severity Index; PASDAS=Psoriatic Arthritis Disease Activity Score; PASI=Psoriasis Area and Severity Index; sIGA=static Investigator’s Global Assessment; SPARCC=Spondyloarthritis Research Consortium of Canada Enthesitis Index; VLDA=very low disease activity.

 

1. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355.
2. Smolen JS, et al. Ann Rheum Dis. 2018;77(1):3-17.
3. Mease PJ, et al. Semin Arthritis Rheum. 2018;47(6):786-796.
4. Wong PCH, et al. Int J Rheumatol. 2012;2012:839425.
5. Simpson MJ, et al. J Eur Acad Dermatol Venereol. 2015;29(7):1415-1420.
6. Kerschbaumer A, et al. Best Pract Res Clin Rheumatol. 2018;32(3):401-414.
7. Acosta Felquer ML, et al. Clin Rheumatol. 2014;33(9):1323-1330.

 

“…due to the heterogenous nature of psoriatic arthritis, measuring disease activity is a challenge – there is no single instrument that reflects activity across all disease manifestations.” – Dr. Alexis Ogdie

 

 

 

“There are generally two approaches when measuring disease activity in psoriatic arthritis – a unidimensional approach and a multidimensional approach.” – Dr. Philip Mease

 

 

II. The selection of a disease activity measure and a treatment target should be individualized according to the current clinical manifestations of the disease.1

Patients with PsA present different clinical manifestations and can be affected by multiple disease domains simultaneously. However, PsA most commonly manifests as a skin and articular disease.2
 

SpA=spondyloarthritis.

1. Smolen JS, et al. Ann Rheum Dis. 2018;77(1):3-17.
2. Ritchlin CT, et al. N Engl J Med. 2017;376(10):957-970.
3. Mease PJ, et al. RMD Open. 2019;5(1):e000867.
4. van der Heijde D, et al. Arthritis Res Ther. 2020;22(1):18.
5. Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071.
6. Merola JF, et al. Rheumatol Ther. 2019;6(1):33-45.

 

Considering the importance of treating joint manifestations in patients with PsA, there are unidimensional and multidimensional composite measures that focus on peripheral arthritis.1,2

RA=rheumatoid arthritis.

1. Wervers K, et al. Rheumatology (Oxford). 2019;58(12):2251-2259.
2. Mease PJ, et al. Semin Arthritis Rheum. 2018;47(6):786-796.
3. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355.
4. Kerschbaumer A, et al. Best Pract Res Clin Rheumatol. 2018;32(3):401-414.
5. Acosta Felquer ML, et al. Clin Rheumatol. 2014;33(9):1323-1330.
6. Anderson J, et al. Arthritis Care Res (Hoboken). 2012;64(5):640-647.

 

“The DAS28 or CDAI equivalent in PsA is the DAPSA, an arthritis-focused disease activity measure.”
 – Dr. Alexis Ogdie

 

 

“Data from clinical trials indicate that PASDAS is better at distinguishing treatment effect than DAPSA or DAS28.”
– Dr. Philip Mease

 

 

III. Defining disease control in PsA and determining appropriate treatment targets

1. Smolen JS, et al. Ann Rheum Dis. 2018;77(1):3-17.
2. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355.
3. Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
4. Mease PJ, et al. Semin Arthritis Rheum. 2018;47(6):786-796.
5. Coates LC, et al. Arthritis Res Ther. 2018;20(1):272. 

 

Determining Disease Control and Remission for a Patient With PsA Through Various Composite Measures1-4

Maria is a hypothetical patient with PsA. Based on the component scores listed below and the composite measure used, Maria’s disease activity status may vary significantly.

 

1. Mease PJ, et al. Semin Arthritis Rheum. 2018;47(6):786-796.
2. Coates LC, et al. Arthritis Res Ther. 2018;20(1):272.
3. Wervers K, et al. Rheumatology (Oxford). 2019;58(12):2251-2259.
4. Anderson J, et al. Arthritis Care Res (Hoboken). 2012;64(5):640-647.

 

“In my clinical practice, we commonly use both cDAPSA and MDA, since cDAPSA can be calculated from a subset of the MDA elements.” – Dr. Alexis Ogdie

 

 

“When setting treatment targets for my patients with PsA, I typically evaluate the items that constitute the MDA and VLDA criteria and strive for VLDA if possible.” – Dr. Philip Mease

 

 

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