Early initiation of anti-TNF therapy in psoriatic arthritis (PsA) almost doubles the rate of remission and challenges the classical step-up approach to therapy, according to a study from the Netherlands.
The study randomised 51 patients with a median duration of disease of 0.5 years to either a combination of methotrexate (25 mg/wk) with golimumab (50mg monthly) or methotrexate and placebo.
All patients were naive to both drugs but other allowed co-medications included NSAIDs and systemic steroids.
The study found 81% of patients on combination therapy achieved a Disease Activity Score (DAS) CRP remission at week 22 compared to 42% of patients on methotrexate and placebo.
A similar proportion of patients (81%) receiving the anti-TNF also achieved Minimal Disease Activity (MDA) at 22 weeks compared to just 29% of the patients on methotrexate.
The findings were supported by other outcome measures such as ACR20 response (85% v 58%), ACR50 (91% v 33%) and ACR70 (58% v 13%).
Patient reported outcome measures including pain, a global score and morning stiffness further demonstrated the benefits of an anti-TNF.
However there were no significant differences in physical functioning and health-related quality of life scores between the two groups at week 22.
The incidence of adverse events was also similar in both arms of the study.
The researchers said the effect of the anti-TNF was evident as early as eight weeks but more pronounced by 22 weeks.
“It remains unknown if the responses—in particular the stringent responses such as remission— have already plateaued at week 22 or could even further increase over time. Similarly, it remains to be determined if the combination of TNFi and MTX is only needed for the induction of remission or is also needed to maintain this state of remission over time.”
The researchers added there was no evidence that patients with psoriatic arthritis would not respond similarly to other anti-TNFs.
“Whether the concept also applies to other biologic targeted therapies used in PsA (anti-IL-17A, anti-p40, anti-p19) remains to be investigated.”
“The early and consistent improvement in stringent response criteria in favour of the golimumab + MTX arm confirms and extends the results of the open-label RESPOND study that early initiation of TNFi contributes to achieve low disease activity or even remission in PsA.”