Using Treat-to-Target for PsA

Treat-to-target (T2T) began as a strategy for managing diabetes and heart disease and is now the most widely accepted treatment approach for rheumatoid arthritis (RA) and other inflammatory diseases. But experts say T2T can be more complex for people with psoriatic arthritis (PsA).

How T2T Works

In treat-to-target, medications are adjusted over time to reach a predetermined treatment goal. The ultimate aim is achieving remission (the absence of signs or symptoms of disease activity). But if you have long-standing disease, low disease activity – meaning there are very few signs of disease – is an acceptable goal.

Depending on your disease activity and overall health, monitoring can occur as frequently as monthly, or less frequently (such as every three to six months). At each office visit, you are evaluated to see if you’ve reached the goal. If not, medication dose is increased, new drugs are added or you may be switched to a different drug class. The process continues, using increasingly aggressive therapies, until you come as close to remission or low disease activity as possible.

T2T has not been the standard of care in PsA, as it is in RA, but guidelines from the American College of Rheumatology now recommend T2T for psoriatic arthritis, too. PsA can be more complicated than RA. It has at least five distinct domains: joints, spine, skin and nail disease, dactylitis (a sausage-like swelling of the fingers or toes) and enthesitis (inflammation where tendons and ligaments attach to bone). Most patients don’t have symptoms in every domain, but each must be taken into account when formulating treatment targets. This is because there isn’t much correlation between improvement in one domain of PsA and improvement in others.

T2T Put to the Test

In a clinical trial to assess T2T in PsA – the Tight Control of Psoriatic Arthritis (TICOPA) Trial – 206 patients with early PsA were randomized to receive standard care or tight control/management for 48 weeks.

The tight control group saw their doctors once a month. Using predetermined targets and a specific protocol, they were treated with disease-modifying antirheumatic drugs (DMARDs) using minimal disease activity (MDA) as the goal. The standard care patients were seen once every 12 weeks, and were treated as deemed appropriate by their doctor with no set protocol to guide their treatment regimen.

Results showed that skin and joint symptoms and patient-reported outcomes improved significantly in the group using MDA as the treatment target. The study authors didn’t choose remission (defined as no symptoms across all PsA domains) as a target because, they said, “it’s hard to achieve.” MDA was an easier goal. Patients in the trial were considered to have achieved MDA if they met five of seven criteria, including having few or no swollen and tender joints and very little skin involvement, pain or disability.

However, trial criteria can be tricky to implement in clinical practice. In the TICOPA trial, if a patient was very close to achieving MDA in five of the seven categories the clinician was forced to tweak the therapy, either by intensifying the dose or switching to anti-TNF [anti-tumor necrosis factor] therapies. This improved symptoms, but also showed a significant increase in adverse events.

What Matters to Patients

Philip Mease, MD, a clinical professor at the University of Washington School of Medicine in Seattle and a founder and past president of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), helped develop GRAPPA’s PsA management recommendations, published in 2016. They include evidence-based recommendations for each of PsA’s key domains, but even Dr. Mease says there’s more to managing PsA than treatment goals.

“It’s good to shoot for minimal disease or remission, but you also have to take into account how patients look and feel – whether they are more functional and productive,” says Dr. Mease. “It’s essential to have conversations about what matters most to them. If someone has a patch of severe psoriasis or very bad nail disease and is working in the jewelry department at Nordstrom, then treating those symptoms is more important to that patient than treating knee inflammation. That’s the beauty of the conversation; patients are able to prioritize what is most important to them and hopefully the rheumatologist will track that issue from visit to visit.”

Although treatment choices can be patient-driven, the benefits and harms of any therapy need to be weighed and regularly assessed by your doctor. Dr. Mease and others say about 40% of patients with PsA can expect to achieve minimal disease activity. While disease remission is an ultimate goal, zero disease activity across all PsA domains is hard to achieve.