Sir, I read with interest the recent article by van Mens et al.  reporting residual disease among patients with PsA judged to be in an acceptable disease state by their treating rheumatologist, with one-third of patients not meeting minimal disease activity (MDA). The authors highlight the discordance between patient and physician assessment of disease and the need for future strategy trials in this patient group. This study is timely and raises additional points of interest. The role of co-morbid FM in the assessment of PsA was not specifically reported in the study by van Mens et al. , but is known to influence physician- and patient-reported outcome. In a study by Brikman et al. , all the instruments used to assess PsA (including MDA) were scored higher/worse among patents with co-morbid FM. Patient-reported measures and physician clinical assessment of tenderness (joints and entheses) are most susceptible to influence from co-morbid FM, and Marchesoni et al.  have reported potential distinguishing features. In the present study by van Mens et al. , the physician-reported outcomes were generally very low in the group categorized as not in MDA, but patient-reported measures, such as patient global, pain and BASDAI, were all higher, indicating the potential influence of co-morbid FM (rather than discordance attributable to residual inflammatory disease). To complicate matters further, PsA is known to be a multifaceted disease, with articular and extra-articular manifestations, varying disease phenotypes, transition between phenotypes during disease course and influence from co-morbidities. It is therefore of vital importance that all domains of disease are assessed before making treatment decisions . The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis have proposed composite scores to capture all domains of disease beyond articular disease, such as enthesitis, dactylitis and skin, nail and axial disease, in a single measure . These composite measures were developed with little patient involvement, and it is likely that some of the discordance noted in the study by van Mens et al.  is related to the lack of representation of the lived experience of PsA (through patient representation in the development process), and work is underway to refine these composite measures with greater representation of the patient perspective . The authors discuss the potential impact of residual disease when treating to target in PsA. There is certainly a need for more treatment strategy trails in the wake of the TIght COntrol of Psoriatic Arthritis (TICOPA) trial, which demonstrated improved outcome for patients treated to the target (MDA), but with an associated higher incidence of adverse events . This needs to be interpreted in light of the varying disease severity seen in PsA, with an estimated 20% never developing structural damage through to the 5% who develop the destructive arthritis mutlilans . Although there is no doubt we should focus on understating the discrepancies between patient and physician assessment of disease, given the challenges of assessment stated herein, the focus of future strategy trails should be on the impact of treat to target on different clinical disease phenotypes (monoarthritis/oligoarthritis, polyarthritis, DIP joint disease and arthritis mutilans). In conclusion, the data from van Mens et al.  highlight not only the need to understand the discrepancies between patient and physician assessments but also the need for incorporation of both the patient and physician perspective in planned refinements to candidate composite measures, the need to account for co-morbid FM in the assessment of PsA and the need for strategy trials in differing disease phenotypes. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: The author has declared no conflicts of interest. References 1 van Mens LJJ, Turina MC, van de Sande MGH et al. Residual disease activity in psoriatic arthritis: discordance between the rheumatologist’s opinion and minimal disease activity measurement. Rheumatology 2018;57:283–90. 2 Brikman S, Furer V, Wollman J et al. The effect of the presence of fibromyalgia on common clinical disease activity indices in patients with psoriatic arthritis: a cross-sectional study. J Rheumatol 2016; 43: 1749– 54. Google Scholar CrossRef Search ADS PubMed 3 Marchesoni A, Atzeni F, Spadaro A et al. Identification of the clinical features distinguishing psoriatic arthritis and fibromyalgia. J Rheumatol 2012; 39: 849– 55. Google Scholar CrossRef Search ADS PubMed 4 Tillett W, McHugh N. Treatment algorithms for early psoriatic arthritis: do they depend on disease phenotype? Curr Rheumatol Reports 2012; 14: 334– 42. Google Scholar CrossRef Search ADS 5 Helliwell PS, FitzGerald O, Fransen J et al. The development of candidate composite disease activity and responder indices for psoriatic arthritis (GRACE project). Ann Rheum Dis 2013; 72: 986– 91. Google Scholar CrossRef Search ADS PubMed 6 Dures E, Hewlett S, Lord J et al. Important treatment outcomes for patients with psoriatic arthritis: a multisite qualitative study. Patient 2017; 10: 455– 62. Google Scholar CrossRef Search ADS PubMed 7 Coates LC, Moverley AR, McParland L et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet 2015; 386: 2489– 98. Google Scholar CrossRef Search ADS PubMed 8 Tillett W, Helliwell PH. The natural history of psoriatic arthritis. In: Adebajo A, Boehncke W-H, Gladman DD et al. , eds. Psoriatic Arthritis and Psoriasis: Pathology and Clinical Aspects . Cham: Springer International Publishing; 2016: 39– 42. Google Scholar CrossRef Search ADS © The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: firstname.lastname@example.org
Rheumatology – Oxford University Press
Published: Feb 1, 2018
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