Background Currently there are many guidelines for the management of psoriatic arthritis which advocate the use of DMARDs (Disease Modifying Anti-Rheumatic Drugs) such as the EULAR (2011) and the BSR (2012) guidelines. These guidelines are based on systematic reviews comparing DMARD to placebo rather than head to head trials.
Objectives The purpose of the survey is firstly to establish whether clinicians in our region were managing psoriatic arthritis in line with recommendations, and secondly, to explore the reasons behind choice of DMARDs or biologic agent.
Methods An anonymous regional survey of 25 clinicians was conducted based around the diagnosis, classification and management of psoriatic arthritis.
Results The most popular classification for PsA is the Moll and Wright's criteria (39%). Methotrexate is the first choice DMARD in oligoarthritis (77%) and polyarthritis (96%). The reasons being: evidence based (31%) prior experience (31%) and to manage the skin condition (38%). The majority favour leflunomide (60%) over sulphasalazine (32%) as second line DMARD. Factors influencing this choice consisted of: evidence (52%); prior experience (28%); safety (12%); likelihood of improving the skin condition (8%). Of the 76% of clinicians who stated they regularly use outcome measures, 67% used PsARC of which 50% use it sometime, 43% always, and 7% rarely. DAS is used by 19% while 14% noted tender or swollen joint counts. Only few clinicians actively subcategorise dactlitis (17%) and enthesitis (36%). The majority (83%) didn't distinguish between PsA and Ankylosing Spondylitis. Popular first choice biologic agents were adalimumab (58%): golimumab (13%): certolizumab (13%). The reasons being: prior experience (37%), articular efficacy (21%), and extra-articular efficacy (16%).
Conclusions The majority of clinicians use PsARC for outcome measurement although not many use it frequently. This may be due to a relatively small cohort of patients on biologic treatment who would need this score to meet criteria to continue biologic therapy. The majority of clinicians didn't distinguish between PsA and Ankylosing Spondylitis which may affect management.There is a general consensus in the East of England region regarding first line DMARD therapy as Methotrexate despite the lack of evidence. There are only few randomised controlled trials showing articular efficacy of DMARDs in psoriatic arthritis but they do show symptomatic benefit. Over half of clinicians use Adalimumab as the first line biologic agent. BSR guidelines (2012) recommend the use of an anti TNF monoclonocal antibody in those who require rapid control of skin psoriasis. Other suggested considerations included cost effectiveness and patient preference which were not stipulated in this survey. The reasons for biologic choice vary but at least a third of all clinicians rely on their prior experience.
Ann Rheum Dis 2012;71:319–326 doi:10.1136/ard.2011.150995
Burden AD, Hilton Boon M, Leman J, et al. Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance. BMJ 2010;341:c5623.
Disclosure of Interest None declared