Paradigms of treatment in PsA

Abstract

Psoriatic arthritis (PsA) is a heterogeneous and multisystem disorder which requires careful collaborative management. In many cases both dermatologists and rheumatologists will be involved in the care of a patient and collaborative working between them can optimise management and patient satisfaction. Recent Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations provide an evidence-based review of therapies in PsA across skin, nail and musculoskeletal domains of PsA as well as guidance for management of comorbidities. Despite increasing evidence for individual therapies in PsA, research into treatment strategies is still lacking. There is mounting evidence for a benefi t of early diagnosis within observational cohorts but no randomised trials of early intervention. Most physicians follow a “step-up” regime for PsA and this is supported by the EULAR treatment recommendations. Given the lack of evidence for early combination therapy and the potential toxicity of therapies it seems to be the best option at present. The Tight Control of PsA (TICOPA) study used a step up regime but compared tight control to an objective target (minimal disease activity) to standard care. This study has provided the fi rst evidence of the benefi t of treating to a pre-specifi ed target in PsA although further research into treatment strategies are warranted. There is also some early evidence that although treatment withdrawal in PsA often leads to a fl are of disease, dose reduction with biologic therapies may be possible in individuals responding well to therapy.