Best Practices in Individualizing Care for Patients With axSpA or PsA

Best Practices in Individualizing Care for Patients With axSpA or PsA Posted By:

Psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) are progressive, chronic inflammatory musculoskeletal conditions that cause significant joint destruction and decreased quality of life. There is considerable overlap in the clinical presentation of and available therapies for PsA and axSpA. Healthcare professionals (HCPs) on the frontline of screening for, diagnosing, and managing these rheumatologic conditions are challenged to discern these nuances to optimize outcomes. Recent guidance for these conditions has shifted to a domain-based paradigm for care, which highlights the importance of a patient-centric, individualized management approach.

Updates in Management of Axial Spondyloarthritis
Symptoms of axSpA typically present in patients younger than 40 years of age. The onset is gradual and characterized by neck and back pain associated with prolonged morning stiffness. This pain is typically relieved by exercise but not rest. Patients may also complain of alternating buttock pain, as well as pain in the hips, shoulders, and other areas.

Domains in Therapy Selection
AxSpA, PsA, psoriasis, inflammatory bowel disease (IBD), and noninfectious uveitis comprise a unique group of immune-mediated diseases with shared immunopathology. Patients often have clinical features of 1 or more of these diseases or what is referred to as multidomain disease. The domains of axSpA (ie, spondylitis, psoriasis, enthesitis, enterocolitis, dactylitis, uveitis, and peripheral synovitis) that are relevant to the patient should be considered when choosing treatment options. To help guide individualized therapy, Brüner and colleagues developed the term spondylitis-psoriasis-enthesitis-enterocolitis-dactylitis-uveitis-peripheral synovitis or SPEED-UP spectrum disease and categorized any currently FDA- or European Medicines Agency–approved biologic or targeted synthetic therapy options by their respective indication(s) by domain. The American College of Rheumatology (ACR), Spondylitis Association of America (SAA), and the Spondyloarthritis Research and Treatment Network (SPARTAN) (ACR/SAA/SPARTAN) published a treatment algorithm in 2019 that incorporated the domains into guidance considerations.

Impact of Therapy on Disease Progression
In a systematic review, Baraliakos and colleagues analyzed the results of 20 studies evaluating the effects of biologic therapies in axSpA on spinal radiographic progression. Using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), investigators found minimal and slow spinal progression in patients receiving long-term TNF inhibitor therapy. Patients receiving a continuous IL-17A inhibitor (secukinumab) also showed less spinal progression and were stable over 4 years. The key takeaway is that the use of biologic therapy for management of axSpA may delay progression of spinal damage. Additional research is needed to confirm these beneficial outcomes.

Updates in the Management of Psoriatic Arthritis
Patients with PsA often present with fatigue, functional limitations, and sleep disturbances. There are also several comorbidities and extra-articular manifestations associated with PsA, which result in increased morbidity and mortality, including uveitis, IBD, cardiovascular disease, obesity, diabetes, hypertension, hyperlipidemia, depression, and anxiety. All these factors may play an important role in treatment selection. 

Delayed Diagnosis of PsA
In a study evaluating 283 patients with PsA, Haroon and colleagues found that the average time from symptom onset to assessment by rheumatology healthcare professionals was 1 year. A diagnostic delay of more than 2 years was associated with low BMI and low education status. Long-term follow-up showed that a delay in specialist evaluation of more than 6 months resulted in more disease-related erosions, osteolysis, sacroiliitis, arthritis mutilans, deformed joints, therapy failure, and worse disability. Therefore, early assessment and diagnosis of PsA is key for avoiding worsened long-term psoriatic disease outcomes, negative impacts on comorbidities and complications, and therapeutic failures.

Individualizing Treatment Plans
Like patients with axSpA, most patients with PsA also present with multidomain disease activity. When planning treatment of PsA with pharmacologic systemic treatments, the current European League Against Rheumatism (EULAR) guidelines recommend considering the disease activity in domains associated with active PsA (ie, polyarthritis [>4 joints] with or without dactylitis, mono- or oligoarthritis, enthesitis, and axial disease).

In addition, the 2021 treatment recommendations from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) support a therapeutic approach guided by disease activity within 6 PsA domains including peripheral arthritis, axial disease, enthesitis, dactylitis, skin and nail psoriasis plus the PsA-related comorbidities, uveitis, and IBD.

Patient-Centered Approach to Management
When considering therapeutic strategies for either axSpA or PsA, HCPs should first conduct a thorough assessment to understand which associated disease domains and comorbidities are involved for their patient. The use of treatment algorithms like ACR/SAA/SPARTAN or GRAPPA is invaluable in selecting therapies that have favorable efficacy and safety profiles for all affected domains.


Filed under: Rheumatology

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