ACHIEVEMENT OF MINIMAL DISEASE ACTIVITY AND PROGRESSION OF RADIOGRAPHIC CHANGES IN EARLY PSORIATIC ARTHRITIS ONE YEAR AFTER INITIATION OF TREATMENT IN «TREAT TO TARGET» STRATEGY (PRELIMINARY RESULTS OF THE REMARKA STUDY)

Achievement of minimal disease activity (MDA) is the main goal of the Treat-to-target (T2T) strategy in early psoriatic arthritis (ePsA). Radiographic progression in patients with ePsA treated according to the T2T strategy has been studied insufficiently. Objective: To study the frequency of achievement of MDA and X-ray progression in patients with early PsA treated according to the T2T strategy 1 year after initiation of treatment. Subjects and methods. Forty patients (22 women) with active ePsA, who met the CASPAR criteria (mean age was 38,4±11,1 years, the median duration of PsA – 7,0 [4,0; 18,0] months, the duration of psoriasis – 38,0 [9,5; 114,0] months, DAS – 3,8 [3,2; 4,7]), were included in the REMARKA study. At the start of the study all patients received subcutaneous methotrexate (MTX) in a dose of 20–25 mg/week. If high or moderate disease activity persisted after 3–6 months, patients (n=21) were transferred to combined therapy with MTX and a biological agent (BA). The remaining 19 patients continued MTX monotherapy. Initially and one year later, the MDA criteria were evaluated (tender joint count ≤1, swollen joint count ≤1, PASI ≤1 or BSA ≤3, pain on visual analog scale (VAS) ≤15 mm, patient global assessment of activity on VAS ≤20 mm, HAQ ≤0,5, tender enthesis count ≤1) and digital radiography of hands and feet was performed. Radiographic progression was assessed by an independent radiologist using the modified method of Sharp/van der Heijde: total score (TS) = erosion score (ES) + joint space narrowing score (JSNS). Results and discussion. At the time of enrollment, 23 patients (57%) with ePsA had erosions. One year later the number of patients with erosions increased to 26 (65%). The TS has significantly increased, although its median has not changed (before treatment – 91.5 [72; 108,5], after one year – 91.5 [73,5; 111,5], p<0,01). In this case, the median of the ES increased from 2 [0; 4,5] to 2,5 [0; 5], (p><0,05), and the median of the JSNS – from 85 [69; 105] to 87 [71,5; 107], (p><0,01). After one year, there was no significant difference between patients receiving MTX monotherapy and MTX + BA, according to TS (p>0,05). In 29 out of 40 patients (72,5%), no radiographic progression was detected neither in the ES nor in the JSN; 13 out of 29 (45%) received MTX and 16 (55%) – MTX + BA. In 11 out of 40 (27,5%) patients, negative radiographic changes according to ES (n=10) and JSNS (n=4) were detected, with three patients having progression in both scores. In this group, 6 patients (54,5%) received MTX monotherapy and 5 (45,5%) – MTX + BA. After 1 year, 25 (62,5%) patients achieved MDA. Among patients who did not achieve MDA (n=15) after 1 year, the ES was significantly higher at the beginning of the study compared to those who achieved MDA: median 3 [2; 9] and 0 [0; 3], respectively (p<0,05). In the group of patients who did not achieve MDA in a year, radiographic progression was more significant. Conclusion. In russian cohort more than half of patients with ePsA had erosions. After one year of follow up 72,5% of patients with ePsA treated according to the T2T strategy showed no radiographic progression, and a quarter of patients (27,5%) had negative radiographic changes, regardless of the type of the therapy. Patients with ePsA, who achieved MDA, had less prominent radiographic progression in a year. Keywords: early psoriatic arthritis; treat to target strategy; radiographic progression; minimal disease activity>< 0,05). In the group of patients who did not achieve MDA in a year, radiographic progression was more significant. Conclusion. In russian cohort more than half of patients with ePsA had erosions. After one year of follow up 72,5% of patients with ePsA treated according to the T2T strategy showed no radiographic progression, and a quarter of patients (27,5%) had negative radiographic changes, regardless of the type of the therapy. Patients with ePsA, who achieved MDA, had less prominent radiographic progression in a year.

1. Коротаева ТВ. Псориатический артрит. В кн.: Насонов ЕЛ, редактор. Российские клинические рекомендации. Ревматология. Москва: ГЭОТАР-Медиа; 2017. 464 с. [Korotaeva TV. Psoriatic arthritis. In: Nasonov EL, editor. Rossiiskie klinicheskie rekomendatsii. Revmatologiya [Russian clinical guidelines. Rheumatology]. Moscow: GEOTAR-Media; 2017. 464 p.].

2. Haque N, Lories RJ, de Vlam K. Orthopaedic interventions in patients with psoriatic arthritis: a descriptive report from the SPAR cohort. Rheumatic Musculoskeletal Dis. 2016;2:e000293.

3. doi: 10.1136/rmdopen-2016-000293

4. Kane D, Stafford L, Bresnihan B, et al. A prospective, clinical and radiological study of early psoriatic arthritis: an early synovitis clinic experience. Rheumatology (Oxford). 2003;42(12):1460-8. doi: 10.1093/rheumatology/keg384

5. Gladman DD, Thavaneswaran A, Chandran V, et al. Do patients with psoriatic arthritis who present early fare better than those presenting later in the disease? Ann Rheum Dis. 2011;70(12):2152-4. doi: 10.1136/ard.2011.150938

6. Theander E, Husmark T, Alenius GM, et al. Early psoriatic arthritis: short symptom duration, male gender and preserved physical functioning at presentation predict favorable outcome at 5-year follow-up. Results from the Swedish Early Psoriatic Arthritis Register (SwePsA). Ann Rheum Dis. 2013;73(2):407-13.

7. Haroon M, Gallagher P, Fitzgerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2014; published online Feb 13. doi: 10.1136/annrheumdis-2013-204858

8. Kavanaugh A, van der Heijde D, Beutler A, et al. Radiographic progression of patients with psoriatic arthritis who achieve minimal disease activity in response to golimumab therapy: results through 5 years of a randomized, placebo-controlled study. Arthritis Care Res. 2016;68:267-74. doi: 10.1002/acr.22576

9. Coates LC, Fransen J, Helliwell PS. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis. 2010;69(1):48-53. doi: 10.1136/ard.2008.102053

10. Coates LC, Helliwell PS. Validation of minimal disease activity criteria for psoriatic arthritis using interventional trial data. Arthritis Care Res. 2010;62:965-9. doi: 10.1002/acr.20155

11. Coates LC, Helliwell PS. Comment on: Efficacy and safety of anti-TNF therapies in psoriatic arthritis: an observational study from the British Sosiety for Rheumatology Biologics Register. Rheumatology. 2010;49:1793-4. doi: 10.1093/rheumatology/keq138

12. Coates LC, Navarro-Coy N, Brown SR, et al. The TICOPA protocol (Tight Control in Psoriatic Arthritis: a randomized controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Musculoskel Disor. 2013;14:101. doi: 10/1186/1471-2474-14-101

13. Coates LC, Moverley AR, McParland L, et al. Effect of tight control inflammation in early psoriatic arthritis (TICOPA): a UK multicenter, open-label, randomized controlled trial. Lancet. 2015;386:2489-98. doi: 10.1016/S0140-6736(15)00347-5

14. Van der Heijde D. How to read radiographs according to the Sharp/Van der Heijde method. J Rheumatol. 2000;27:261-4.

15. Коротаева ТВ, Логинова ЕЮ, Каратеев ДЕ и др. Стратегия «лечения до достижения цели» при раннем ПсА (предварительные результаты исследования РЕМАРКА). Научно-практическая ревматология. 2014;52(4):376-80 [Korotaeva TV, Loginova EYu, Karateev DE, et al. Treat-to-target strategy for early psoriatic arthritis (preliminary results of the REMARCА study). Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2014;52(4):376-80 (In Russ.)]. doi: 10.14412/1995-4484-2014-376-380

16. Harrison BJ, Silman AJ, Barrett EM, et al. Presence of psoriasis does not influence the presentation or short-term outcome of patients with early inflammatory polyarthritis. J Rheumatol. 1997;24(9):1744-9.

17. Lindqvist U, Alenius G-M, Husmark T, et al. The Swedish early psoriatic arthritis register – 2-year followup: a comparison with early rheumatoid arthritis. J Rheumatol. 2008;35(4):668-73.

18. Faustini F, Simon D, Oliveira I, et al. Subclinical joint inflammation in patients with psoriasis without concomitant psoriatic arthritis: a cross-sectional and longitudinal analysis. Ann Rheum Dis. 2016;0:1-7. doi: 10.1136/annrheumdis-2015-208821

19. Punzi L, Pianon M, Rossini P, et al. Clinical and laboratory manifestations of elderly onset psoriatic arthritis: a comparison with younger onset disease. Ann Rheum Dis. 1999;58(4):226-9.

20. doi: 10.1136/ard.58.4.226

21. Красненко СО, Логинова ЕЮ, Коротаева ТВ и др. Сравнительная характеристика данных магнитно-резонансной томографии, рентгенографического и клинического исследования кистей и стоп у больных с ранним псориатическим артритом. Научно-практическая ревматология. 2013;51(2):149-53 [Krasnenko SO, Loginova EY, Korotaeva TV, Smirnov AV. Comparative characterization of the data of magnetic resonance imaging, X-ray and clinical studies of the hand and foot joints in patients with early psoriatic arthritis. Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2013;51(2):149-53 (In Russ.)]. doi: 10.14412/1995-4484-2013-642

22. Geijer M, Lindqvist U, Husmark T, et al. The Swedish early psoriatic arthritis register 5-year followup: substantial radiographic progression mainly in men with disease activity and development of dactyli-tis. J Rheumatol. 2015;42:2110-7. doi: 10.3899/jrheum.150165