New Initiative to Help Define Difficult-to-Treat Axial Spondyloarthritis (axSpA) and Psoriatic Arthritis (PsA)

Introduction

Despite the wide range of disease-modifying antirheumatic drugs (DMARDs) available, a considerable number of patients struggling with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) cannot achieve remission even after trying several treatments. This has led experts from various parts of the world to embark on an initiative to define these “difficult-to-treat” patients carefully. It is projected that by defining these categories, stakeholders can improve medical care and, more importantly, enhance future clinical trials.

Defining Difficult-to-Treat

According to Denis Poddubnyy, MD of the Charité – Universitätsmedizin Berlin and the German Rheumatism Research Center Berlin, difficult-to-treat axSpA defines patients who don’t achieve 40% improvement in ASAS response criteria (ASAS40) after trying all available DMARDs. He further stated that there was no clear guidance on how to manage these patients, according to the current clinical guidelines. Difficult-to-manage and complex-to-manage definitions have been used to describe this heterogeneous population of non-responders in different professional societies.

The Biologically Refractory Disease

True biologically refractory inflammatory disease only makes up a fraction of cases that respond inadequately to treatment. Apart from articular and periarticular inflammation, non-inflammation factors may contribute to this treatment-resistant ailment, including comorbidities like obesity, cardiovascular disease, fibromyalgia, and even social factors such as limited access to drugs.

The Psoriatic Arthritis Program by the Medical College of Wisconsin

According to Dr. Shikha Singla, director of the psoriatic arthritis program at the Medical College of Wisconsin, more work needs to be done in delineating the elements that contribute to treatment refractory disease. As opposed to axSpA, differentiating the biologically refractory disease from other cases is vital in psoriatic arthritis.

Contributing Factors

Aside from depression and hypersensitization, patients’ lack of faith in Western medicine may be a contributing factor to non-adherence to drugs or treatments. In fact, some patients may even seek out alternative medicine approaches, thinking that it is effective.

Useful Definitions for Clinical Practice

These definitions will play a significant role in shaping homogeneous cohorts for future clinical trials in both axSpA and PsA. Dr. Fabian Proft highlights the importance of a unified definition to improve the patient’s outcomes in clinical trials. However, in clinical practice, the complex/difficult-to-manage definition may be more useful. If a patient is not responding to treatment, it is vital to identify the root cause of the problem before making any medication changes.

Conclusion

Difficult-to-treat or complex-to-manage patients require a more intensive approach to adequately find the cause of non-response to treatment. The use of heterogeneous definitions in professional societies makes it difficult to develop a unified approach to tackling these categories. Nevertheless, the joint efforts of the ASAS and GRAPPA will improve the standards of medical care in the future.

Originally Post From https://www.medscape.com/viewarticle/whats-name-defining-difficult-treat-axspa-and-psa-2024a1000b5i

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