Defining the Challenge in Complex Cases of Psoriatic Arthritis

Announcer:
Welcome to Living Rheum on ReachMD. On this episode, we’ll hear from Dr. Laura Coates, who is an NIHR Research Professor and Senior Clinical Research Fellow at the University of Oxford in the United Kingdom. She’ll be discussing how to manage difficult or complex psoriatic arthritis cases.

Here's Dr. Coates now.

Dr. Coates:
I think one of the big moves in the last couple of years has been thinking about groups of patients who are trickier to manage in clinic, and thinking about definitions across rheumatology and different rheumatological diseases for patients who have difficult-to-treat disease or complex-to-manage disease. There's been a lot of work on international consensus to create definitions for these. And the definition I think I really like in psoriatic arthritis is of two groups.

There's a larger group who are complex to manage, and they're patients who maybe have some level of a joint inflammation, but they also have other reasons that make their disease or their symptoms difficult to control. And then within those patients who have complex-to-manage disease, there's a smaller group who have true treatment-resistant arthritis. So they’re patients who have definite inflammation despite use of biologics. Typically, in the definitions that are coming out now, you have to have tried at least two different mode-of-action biologics—so maybe a TNF inhibitor and an IL-17 inhibitor, or a TNF inhibitor and an IL-23 inhibitor. And these are patients who, despite those medications, have not managed to control the pure inflammatory portion of their disease.

And I think it's really important that we have those two definitions. Having a definition for particular patient groups means you can study them. You can discover what works. You can create drug trials specifically for that group. And they’re patients who often don't end up in drug trials. People like easy, relatively recently diagnosed people who haven't been through lots of medications before. But having specific trials for these more complex patients is really important. And we need the two different definitions, because the treatments are gonna be very different. If somebody's got truly treatment-resistant disease with active inflammation, we need to be considering new biologics, combinations of biologics, or completely new treatment approaches with different ways of impacting the immune system to try and improve their outcome and control their disease.

In the complex-to-manage group, they may well not need more disease-modifying therapy. A biologic might not fix things. What they need is different types of treatment. They might need support for fibromyalgia, pain, osteoarthritis, or obesity—other things that we can manage in a very different way, but that will still lead to an improvement in outcome.

Announcer:
That was Dr. Laura Coates sharing her expertise on challenging-to-treat psoriatic arthritis. To access this and other episodes in our series, visit Living Rheum on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!