Prevention of psoriatic arthritis: the next frontier

Psoriatic arthritis is a heterogeneous inflammatory musculoskeletal condition that affects up to a fourth of patients with psoriasis over their lifetime and is notoriously challenging to identify and manage. 1 FitzGerald O Ogdie A Chandran V et al. Psoriatic arthritis. Nat Rev Dis Primers. 2021; 7: 59 Crossref PubMed Scopus (55) Google Scholar Approximately 30% of patients with psoriatic arthritis reach remission after treatment with targeted biological therapies, and average time on therapy is only 1 year. 1 FitzGerald O Ogdie A Chandran V et al. Psoriatic arthritis. Nat Rev Dis Primers. 2021; 7: 59 Crossref PubMed Scopus (55) Google Scholar Given these substandard responses, especially when compared with the substantial amelioration observed in skin psoriasis using the same biological therapies, an alternative strategy for optimising outcomes is to prevent psoriatic arthritis onset; 2 Scher JU Ogdie A Merola JF Ritchlin C Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol. 2019; 15: 153-166 Crossref PubMed Scopus (165) Google Scholar however, addressing prevention in observational studies has proven challenging given their inherent biases. In The Lancet Rheumatology, Shikha Singla and colleagues 3 Singla S Putman M Liew J Gordon K Association between biologic immunotherapy for psoriasis and time to incident inflammatory arthritis: a retrospective cohort study. Lancet Rheumatol. 2023; (published online March 6.)https://doi.org/10.1016/S2665-9913(23)00034-6 Summary Full Text Full Text PDF Scopus (5) Google Scholar offer one approach to assessing the incidence of psoriatic arthritis following treatment with biologics, by utilising electronic medical record (EMR) data from health-care organisations across the USA. By studying different classes of biological therapies over a mean of 2·4 years, they found that the risk of incident psoriatic arthritis was significantly reduced in patients prescribed either a p40 blocker that inhibits interleukin [IL]-12 and IL-23 (ustekinumab; adjusted hazard ratio 0·58, 95% CI 0·43–0·76) or a p19 subunit blocker that inhibits IL-23 (guselkumab, risankizumab, or tildrakizumab; 0·41, 0·17–0·95), compared with patients prescribed tumour necrosis factor (TNF) inhibitors. By contrast, there was no significant effect in patients prescribed IL-17 inhibitors (0·86, 0·54–1·38). Although this study is intriguing and hypothesis-generating, by itself it remains insufficient to spur clinical care towards preferential use of IL-12/23 and IL-23 inhibitors in patients with psoriasis. Association between biological immunotherapy for psoriasis and time to incident inflammatory arthritis: a retrospective cohort studyIn this large cohort study of patients with psoriasis, treatment with IL-12/23 inhibitors or IL-23 inhibitors was associated with reduced risk of progression to inflammatory arthritis compared with TNF inhibitors. Prospective observational cohorts with disease activity measures and pooled analyses of previous randomised trials are required to confirm these findings. Full-Text PDF