Alexis Ogdie, MD, on a Treat To Target Approach to Psoriatic Arthritis

Alexis Ogdie, MD, a rheumatologist and associate professor of medicine at the hospital of the University of Pennsylvania, took some time to talk to the Rheumatology and Arthritis Learning Network about her work in using a treat-to-target approach among patients with psoriatic arthritis (PsA) being treated with biologic and targeted synthetic DMARDs. In this Q&A she discusses an abstract she presented at the American College of Rheumatology Convergence.

Rheumatology and Arthritis Learning Network:  It's good to have you back to talk with us, Dr. Ogdie. Thanks for taking the time.

Alexis Ogdie:  Thanks so much for the opportunity to be here.

RALN:  First of all, can you give us a general overview of your study?

Dr Ogdie:  In this particular abstract, we were interested in seeing what are the impacts of achieving minimal disease activity. We know in clinical practice that we want to implement a treat‑to‑target strategy and minimal disease activity is one of those targets that we aim for. What we wanted to see is when you get patients there, how beneficial is it to the patient?

RALN:  How do you define minimal disease activity? Then, secondarily, how do you define clinically meaningful improvements for the purpose of your research here?

Dr Ogdie:  Great question. Minimal disease activity is achieving 5 of 7 different criteria. The criteria are having a tender joint count of 1 or less. A swollen joint count of 1 or less. A body surface area of psoriasis of 3% or less. A HAQ, which is the Health Assessment Questionnaire of 0.5 or less on a scale 0 to 3. A patient global assessment of 2 or less on a scale of 0 to 10. A patient pain assessment of 1.5 on a scale of 0 to 10. Then, an enthesitis index of 1 or less, as well. You can have to have 5 of the 7 of those in order to be in MDA.

RALN:  What about clinically meaningful improvements?

Dr Ogdie:  In terms of what are clinically meaningful improvements, these are the things that matter to patients. For example, are they having overall less pain? Are they having less fatigue? Are they having less morning stiffness? Is it impacting their work impairment as well?

RALN:  What differences did you find between patients who achieved minimal disease activity and those who did not?

Dr Ogdie:  As you might expect, in general, patients who were in minimal disease activity had significantly less body surface area of psoriasis. They had much better function scales. They had fewer tender and swollen joints. They had much lower pain. Much better global assessment of their overall disease and lower enthesitis.

In addition, they also had much better work ability, so less work impairment. They had less morning stiffness and less fatigue. Overall, they were much better. In addition, people who achieved minimal disease activity had an 18% drop in overall work impairment relative to nonachievers.  That's pretty significant in terms of the amount of potential lost wages, which is estimated to be around $11,000 for an individual over a year. Pretty significant.

RALN:  Very significant. Their quality of life, in general, aside from work impairment, must also be significantly higher?

Dr Ogdie:  Exactly. If you can get someone feeling better, having fewer tender and swollen joints, less pain, obviously, they are going to be more productive and have just generally more quality of life.

RALN:  Was there any significant difference in the numbers of patients treated with biologics versus those treated with targeted synthetic DMARDs who achieved MDA or between biologic-naive and biologic-exposed patients?

Dr Ogdie:  In this particular abstract, we didn't look at people who were on a biologic and those who were on tsDMARDs, but we were mostly focused on how much they were switching medication. In some senses, it makes sense if you're not in minimal disease activity, you were more likely to switch to a different medicine.

Overall, we didn't focus too much on the differences of the proportions of patients achieving MDA, although there were slight differences when you looked at them side by side because this was mostly descriptive in that light. We're not directly comparing them.

RALN:  I see. Ultimately, did you find an association between MDA and clinically meaningful improvement among the research participants?

Dr Ogdie:  We did. One take‑home message from this particular abstract is that treat‑to‑target is meaningful. If you can get someone into minimal disease activity, it has meaningful impacts on their life.

Yet one more reason to be monitoring these aspects of their disease and tweaking the interventions to get to a point where we can get them into that low state of disease activity.

RALN:  That answers my last question, which is what are the implications of this research on clinical practice?

Dr Ogdie:  The implication is to use these treat‑to‑target measures. One of the things that people often in practice say is, "I don't have enough time to do this. There's too many other things that we need to do."  I say to those doctors, I agree with you. There's too many things that we have to do in these short visits, but at the same point, if we want to do something meaningful and impactful, following these measures can help with making those tweaks. This is a high yield thing to be doing in clinical practice.

RALN:  It's worth your time?

Dr Ogdie:  I agree. I think so.