Preventing the Onset of PsA in Patients With Psoriasis

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis that occurs in a significant proportion of individuals with psoriasis. The diagnosis of PsA is often delayed up to 2 years, according to a recent National Psoriasis Foundation survey and other studies, and PsA screening has become a more prominent issue.

This was a major topic at the American Academy of Dermatology annual meeting, and MedPage Today brought together three expert leaders in the field: moderator Andrew Blauvelt, MD, of the Oregon Medical Research Center in Portland, is joined by Joel Gelfand, MD, of the University of Pennsylvania in Philadelphia, and Neil Korman, MD, PhD, of Case Western Reserve University in Cleveland, for a virtual roundtable discussion on the treatment and prevention of PsA. This is the fourth and final of the exclusive episodes.

Following is a transcript of their remarks:

Blauvelt: Hello, everyone. My name is Dr. Andy Blauvelt. I’m a dermatologist from Portland, Oregon, at the Oregon Medical Research Center. I’m happy to be joined today by two of my friends and colleagues, Dr. Joel Gelfand from University of Pennsylvania, and Dr. Neil Korman from Case Western Reserve University.

I want to switch topics lastly, we just have a few more minutes, and talk about psoriatic arthritis. There’s a lot of discussion now about whether our treatments can prevent the onset of psoriatic arthritis. Neil, I’m going to start with you and then I’ll go to Joel. Do you think about this in your psoriasis patients without PSA when you put them on therapy? Do you think or talk about the possibility of preventing PSA? What’s your take on this topic?

Korman: Absolutely, I definitely think about it and I talk about it regularly with my patients, particularly the ones who have relatively new-onset significant disease, who I’m going to be putting on a systemic therapy. And in fact, with just kind of the way that the data is evolving, I’m starting to think about how I’d like to treat people a little earlier with a systemic therapy, and get them on systemic therapy to minimize the chances.

I don’t think the data yet is proof of that. I definitely like to practice evidence-based medicine, but I like to be at the cusp of the evidence-based medicine, and I’d much rather treat too early than too late. Let’s put it that way. And I think that’s a major comorbidity. Our patients who have psoriatic arthritis suffer an enormous amount from their active PSA disease. So if there’s anything that I can do, I will do my best to do that, to try to minimize. And the patients are starting to ask about it, actually. I had a discussion today where somebody actually asked me exactly that question.

Blauvelt: Joel, what do you think of the data right now in this regard as far as prevention of PSA?

Gelfand: Well, first of all, it’s certainly a logical question. Of course, we know a recent paper we published this year in a perspective study we’ve been doing in the United Kingdom, we showed that for every 1% increase in body surface area a patient has, they have a 2% annual increased risk of developing psoriatic arthritis over time, looking at these people prospectively. Does that make sense — if I could reduce their body surface area, shouldn’t that lower their risk of psoriatic arthritis?

Four observational studies came out this past year, one from my group, and they were sort of contradictory. Three of them seem to suggest that if you’re on biologic therapy, lumping all of them together, not looking at one particular mechanism, that those patients generally seem to have a lower risk of being diagnosed with psoriatic arthritis in the ensuing 4 or 5 years, compared to maybe people on pills by mouth, or phototherapy, or topical medications. And our study, which is the largest to date using U.S.-based data, we found the opposite effect. Those getting biologics seem to have higher rates of getting diagnosed with psoriatic arthritis over time.

I think ultimately it’s a very hard question to answer with observational data. Because people are observed differently if you’re on a biologic or not a biologic, things are coded differently if you’re on a biologic or not. So there’s a lot of sources of error that can go either direction.

And I think for our field to really go to another level, the idea of large-scale pragmatic studies, where we randomize our patients to one treatment strategy or another treatment strategy to understand the best effects they have over time, that will give us the best insight into when our therapies are truly disease modifying — the idea that if I could treat rheumatoid arthritis with a certain drug, that those people are going to be less likely to have a disability down the line, that that’s the next phase of research that I think psoriasis needs to go to.

Blauvelt: Yeah, there’s actually a study right now with Cosentyx, looking at patients with disease onset of less than 1 year, and then treating them versus phototherapy, and then seeing whether the treatments can be withdrawn and whether we can actually use this “hit hard-hit early” hypothesis early in the course of disease. Can we make a difference later on, or will we just keep having to treat them forever?

Gelfand: I think it’s a great study. They did this really great, elegant study where they identified people within a year of psoriasis onset, the first study of its kind, and showed people that have scalp disease are the ones most likely to go on to having severe psoriasis over time. So, of course, if we could figure out, like Neil was mentioning earlier, someone’s in their teens or early 20s, they have scalp disease, we knew that intervening with a biologic for a year would spare those people having onset severe disease over time, boy, that would be a real game changer for our patients.

Blauvelt: Yeah. That kind of study’s going to need to be large and long, though, right? To show something like that.

Gelfand: That’s how we make progress.

Korman: That’s always the challenge. All we need is the support to get studies like that done.

Blauvelt: Yeah, and to me it also supports the idea of treating the patient appropriately with a highly effective therapy early. I hate the whole step approach where you go a little bit, little bit, little bit, little bit, and you reserve the best drug to the end. I do the opposite. I’ve always done the opposite. I’ve always tried to get my patients the best drug out there, what I would consider, what I would want, or for my family member. And there may be science to that as far as someday we may have data saying, well that’s the best approach is really kind of get rid of the disease, instead of playing around with it for years.

So with that, I thank you guys for contributing to this discussion. Certainly there’s lots of activity in psoriasis — lots of new data, some new drugs for us to think about, and some great new, interesting things going on with comorbidities. So I appreciate your time, Joel and Neil, and see you at the next meeting.

Korman: Thank you.

Gelfand: Take care.

Watch episode one of this discussion: Cardiovascular Risk in Patients With Psoriasis

Watch episode two of this discussion: Bimekizumab Shows Promise in Moderate to Severe Plaque Psoriasis

Watch episode three of this discussion: Oral TYK2 Inhibitor in Plaque Psoriasis

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