You wouldn’t put a patient on the bus and expect them to get to their destination without telling them where to get off. Don’t do the same thing for your patients with spondyloarthritis, an expert urges.
Implementing a T2T approach in the clinic
Over the past decade a treat-to-target approach in rheumatoid arthritis has improved outcomes for patients. According to a group of international experts the concept can also be applied to other inflammatory diseases such as spondyloarthritis (SpA) and Psoriatic arthritis (PsA) – as long as clinicians follow the patient and have a treatment plan that they can evaluate and modify.
Speaking during a satellite symposium on advancing the quality of care in SpA Professor Dafna Gladman from the Centre for Prognosis Studies in Rheumatic Diseases at the University of Toronto told delegates that a key step towards successfully implementing a treat to target approach in patients with SpA and PsA was to consider all aspects of a patients’ disease.
“We need to talk about the inflammatory components but we also need to look at the extra-articular manifestations and co-morbidities,” she stressed.
However, Professor Gladman acknowledged that SpA and PsA were complex diseases and finding a disease activity measure that encompassed all aspects of the disease and could be used in the clinic was challenging.
What we know about composite disease activity scores
Taking the audience through the advantages and limitations of some of the validated disease activity scores Professor Gladman said that at the moment the Ankylosing Spondyloarthritis Disease Activity Score (ADAS) seemed to be the best instrument to use as a disease activity measure and a target in patients with ankylosing spondyloarthritis.
A score of less than 1.3 reflected inactive disease and a score of less than 2.1 indicated low disease activity.
“Whether [a score of less than 1.3] also reflects no MRI inflammation remains to be determined and that may be another aspect of the evaluation that will need to be incorporated,” she told delegates.
Imaging tools were going to be important but it was unknown how they would fit into the assessment of disease activity in patients.
“We’re learning more and more about how to use these techniques and what joints – and how many joints – we need to use and what specific aspects of the assessment we should include,” she said.
“Over the next few years we’ll probably have a much better description and descriptors of what needs to be incorporated into a T2T approach,” she added.
There was still a lack of consensus for which scoring system to use when measuring the various components of disease activity in PsA, Professor Gladman noted.
“We know that in PsA we need to think about the peripheral arthritis, axial disease entheses dactitlytis skin and nail disease and of course the co-morbidities that are becoming more and more important,” she said.
A number of composite measures had been developed, with some assessing only the joints and some covering most aspects of the disease.
For example, the DAS28 only reflected joint disease and while it could distinguish responders from non-responders in clinical trials it didn’t really work in the clinic, Professor Gladman said.
“When you’re following a patient in a clinic they may only have foot disease and if you’re not evaluating the feet you’re going to think the patient is doing very well when in fact they can’t even walk,” she said.
“You’ve got to think about the assessment in clinical practice which is relevant to the patient,” she advised.
Another score was the CPDAI, which was based on the core domains of PsA and assessed the joints and most of the components of the disease.
The score was graded from 0-15 with a lower score indicating low disease activity or remission.
For example, a patient with a score of 6 should have their therapy changed, whereas a score of less than 6 indicated there was no need to increase therapy, Professor Gladman explained.
Treatment target – minimal disease activity
A useful target for the T2T approach was the minimal disease activity score (MDA) as it represented a realistic target, Professor Gladman said.
Although not a disease activity measure it was a comprehensive treatment target defined by OMERACT that took joints, skin, entheses and patient reported outcomes into account.
“We now know [from TICOPA] if you meet 5 out of 7 of the criteria you are in MDA, if you go to 7 out of 7 you almost have remission, ” she said.
However the MDA was limited in that it doesn’t measure axial disease. According to Professor Gladman it was uncertain whether this was important because, unlike ankylosing spondylitis, axial disease in PsA was often asymptomatic.
“It will be important for us to understand whether the MRI, especially the inflammatory component of the MRI, would be useful in incorporating axial disease to the MDA score,” she said.
Follow the patient and have a plan
Recent updates to the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and EULAR recommendations illustrated the need to follow the patient and have a plan, said Professor Gladman.
“Treat whatever is the most appropriate area to treat – or at least you treat most aggressively according to the area that is most affected in the individual patient,” she explained.
“If a person comes in with primarily peripheral arthritis you treat that as aggressively as possible, but if their main problem is enthesitis that’s what you’re going to direct your attention at.
And because for enthesitis there’s no evidence for DMARDs then you’ll jump from NSAIDs directly to anti-TNFs.”
Likewise, if the axial disease is what you need to treat then you’ll follow the instructions for axial disease, she said.
“Follow the patients regularly and readjust your therapy accordingly…Just putting the patient on the bus and expecting them to get to their destination without telling them where to get off is not going to work,” she told delegates.
“We need to adjust our management to the individual patient, to the individual tolerance, and to the individual disease and modify it as we go along.”
It’s not what you use, it’s how you use it.
At the end of the day the most important thing is not which instrument is used, but whether the patient has been assessed appropriately, Professor Gladman said.
“If you do a joint count and you look for enthesitis, dactylitis, then you look at the skin and nails, and assess whether there is axial involvement you’ve done everything that needs to be done,” she said.
“Then you can plug the numbers in to whatever instrument you wish to use, but the bottom line is assess the patient appropriately,” she stressed.
Professor Gladman said that one of the barriers she often heard from colleagues was a lack of time to assess the patient in a busy clinic.
However, she suggested that some of that limitation was self-imposed.
“We do protocol evaluation on our patients regularly — I can tell you it takes 20 minutes to get a history and do a physical exam,” she told delegates.
“If you are allotting less than 20 minutes to see a patient with a complex disease you’re not doing anybody any favours… patients need to have enough time to be evaluated properly,” she said.
The bottom line is have an individual target
Whether a specific instrument is used or not, it is important for the physician and the patient to have a target to aim towards, Professor Gladman concluded.
“We need to follow a course that is individualised for the patient where the patient and the doctor know they have arrived, or not arrived at that particular target… because that will make the patient better in the long run,” she said.
Professor Gladman said she believed everybody was afraid to aim for remission – or an absence of disease – in patients with SpA and PsA, or even RA, out of a fear that the number of people that achieve that state would be low.
“That’s not the way we should think about it – we should think about getting rid of the disease,” she told the audience.
“When you treat cancer you treat towards remission – you want to get rid of the cancer. When you treat arthritis you should aim to get rid of the arthritis,” she said.
“We’re not there yet, but that’s ok, at least we should have a goal…we may not get there in a lot of patients but if we get there for a proportion of patients that would be great.”
This article was commissioned and sponsored by AbbVie PTy Ltd. Mascot. The content is based on published studies and the speakers’ opinions presented at Abbvie’s Satellite Symposium during EULAR 2016. The views expressed are not necessarily those of AbbVie PTy Ltd. Please consult the full Product Information for any medications mentioned in this article at https://www.ebs.tga.gov.au/before prescribing. Treatment decisions based on these data are the full responsibility of the prescribing physician. HUMS-2016-42.