Despite clear directives outlined in the updated guidelines published by the American College of Rheumatology/National Psoriasis Foundation (ACR/NPF) in 2018, there is limited data regarding medication use in real-world clinical practice and patient medication preferences for the treatment of psoriatic arthritis (PsA).

According to a new study conducted by researchers at Hospital for Special Surgery (HSS) in New York City and presented at the ACR annual meeting, there has been a significant increase in anti-IL17 and anti-phosphodiesterase-4 (anti-PDE4) medications being used as initial treatment for PsA since 2018, which may reflect their inclusion as potential initial therapy in the ACR/NPF guidelines, as well as the importance placed by patients on medication side effects.

Regarding patient medication preferences, we found patients highly value preservation of their joint and function as well as safety. We can use these findings to help us tailor our therapy to achieve the best outcomes for our patients."

Monica Schwartzman, MD, MS, lead study author, rheumatologist at HSS

PsA is a very heterogenous disease with five distinct patterns of arthritis, which can make it challenging to treat. The disease is associated with a myriad of extra articular manifestations, including skin psoriasis, uveitis, and enthesitis, as well as comorbidities such as metabolic syndrome and depression.

The investigators sent surveys to patients in the HSS PsA registry. Preferences were ranked on a five-point Likert scale ranging from "not at all important" to "extremely important." The median age of the 137 respondents was 60 years, and the median duration of PsA skin symptoms, joint symptoms, and PsA diagnosis by a physician was 19, 12, and 8 years respectively.

The survey solicited information regarding phenotypic features and characteristics of the respondent's PsA, demographics, initial and current therapy, and medication preferences. Preference domains included medication efficacy for skin and joint disease, time to onset of efficacy, mode and frequency of administration, cost and insurance coverage, need for laboratory monitoring, side-effect profile, ability to affect function, and advice from physicians, peers, or commercial entities.

The researchers found that 62% of patients were first treated with non-steroidal anti-inflammatory drugs (NSAIDs). The most common initial immunomodulatory medications were anti-tumor necrosis factor (TNF)-α (35%), followed by methotrexate (19%), anti-PDE4 (12.4%), other conventional synthetic disease modifying anti-rheumatic medications (csDMARDs) (11.7%), anti-IL17 (5.1%), and anti-IL23 (2.9%). At survey administration, the most common immunomodulatory therapies were anti-TNF-α (30%), followed by anti-IL17 (20.4%), methotrexate (10.2%), anti-PDE4 (8.8%), other csDMARDs (8.0%), Janus kinase inhibitors (2.2%), and anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA 4) (1.5%), while 28% of patients were not on any immunomodulatory therapy. Following the publication of the 2018 ACR/NPF updated guidelines for PsA, a significantly higher percentage of patients' first medications was an anti-IL17 compared to 2018 or earlier (30% vs 3.5% P<0.001). This pattern was also seen with anti-PDE4 medications (40% vs 11.5% P<0.012).

Medication preferences most respondents ranked as "extremely important" were prevention of joint damage (80%), ability to perform daily activities (71%), prevention of pain (70%), rheumatologist recommendation (63%), and medication side effects (62%).

"At HSS, more patients with PsA are being started on an anti-TNF before methotrexate. This likely reflects the fact that many of these patients have axial disease that methotrexate cannot treat effectively," said Lisa A. Mandl, MD, MPH, a rheumatologist at HSS and a study coauthor. "Patients with PsA, who are often younger, are telling us they want to be treated with medication which will keep them mobile and active. It is important to take into consideration when making therapeutic decisions that alleviating pain is not the only concern. Medications like NSAIDs, which may be effective for pain relief, are not aligned with patient's long-term goals, as they are not an effective disease-modifying agent."

Dr. Schwartzman said the 2018 guidelines on PsA from the ACR/NPF support a wider range of medications as initial therapy. "Over the last decade or so, our treatment armamentarium has expanded in an incredible way for this disease, and it includes medications with novel mechanisms of action." She added the increasing use of newer agents with novel mechanisms of action may "indicate a therapeutic need unfulfilled by traditional medications."

The researchers say more research is needed on the 28% of patients who were not receiving any immunomodulatory therapy. Left untreated, PsA can lead to functional impairment, poor quality of life, and significant morbidity and mortality.