Abstract
Over the last decade, due to the high expectations that biologic drugs like anti-TNF are raising, the appropriate identification of patients eligible for these treatments has been conditioned by numerous ordinary aspects, mainly represented by previous or ongoing comorbidities and related therapies, and chronic infections or recurrence of acute infections. Additionally, in the last years, due to close monitoring by experienced clinicians, remarkable changes have been also obtained in the field of safety. Another question mark refers to the management of psoriatic arthritis systemic manifestations, in which the impact of biologic therapy is not enough explored.
In the recent years, the concept of psoriatic arthritis (PsA), involving electively joints, skin and nail Citation[1,2], has evolved towards the definition of a systemic disease, providing an enlarging spectrum of systemic conditions, called ‘psoriatic disease’ (PsD) Citation[3,4]. At the same time, the progress in the knowledge on PsA pathogenesis allowed us to identify the critical importance of the action of several inflammatory cytokines, in particular TNF-α Citation[5,6]. As a consequence, the introduction of TNF-α blockers in the therapy has opened a new era for patients with PsA, with dramatic improvements of their outcomes, changing also the therapeutic approach towards PsD Citation[7,8]. In addition, newer therapies are of course developed to inhibit precise targets; the advances have taken into consideration to target the IL-12/23 pathway. Ustekinumab, a human monoclonal antibody directed against the common p40 chain of both IL-12 and IL-23, is used for the treatment of psoriasis, and it has also been approved in PsA patients Citation[9]. Other therapeutic targets were IL-6 and T cells; in fact, IL-6 influences T-cell development into TH17 cells, which are important mediators in PsA Citation[10]. Abatacept, a CTLA4-IgG fusion protein, has been shown effective on joints with a less effect on skin lesions Citation[11].
Data on effectiveness and safety of conventional and biological therapies mainly derive from randomized clinical trials (RCTs) and registries Citation[12]. However, in PsA, registries have several limitations in identifying specific toxicity for biologic therapies. Furthermore, the number of RCTs conducted in PsA remains still low, not providing sufficient data on long-term management, and not fully reflecting the real-world practice Citation[13].
Over the last decade, due to the high expectations that biologic drugs like anti-TNF are raising, it became evident that a high professional profile of rheumatologists is needed in order to offer the best care target and to reduce the risk of occurrence of adverse events. In particular, in daily clinical practice, the appropriate identification of patients eligible for these treatments has been conditioned by numerous ordinary aspects, mainly represented by previous or ongoing comorbidities and related therapies, and chronic infections or recurrence of acute infections.
Additionally, in the last years, due to close monitoring by experienced clinicians, remarkable changes have been also obtained in the field of safety Citation[14,15]. Thus, in our opinion, in clinical practice, a correct use of anti-TNF-α therapy could be guaranteed by the expertise of specialized centers devoted to the management of PsA and anti-cytokine therapies.
Another question mark refers to the management of PsA systemic manifestations, in which the impact of biologic therapy is not enough explored Citation[16].
In conclusion, the crucial point for the clinicians is represented by two areas. The first is the management of the individual patient with its heterogeneous complexity. The second one is the awareness that the expertise of specialized centers can contribute to assure a better and safer use of these therapies.
These considerations introduce the interesting and well-documented Review published in the Journal Citation[13].
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Bibliography
- Wright V, Moll JM. Psoriatic arthritis. Bull Rheum Dis 1971;21(5):627-32
- Soscia E, Sirignano C, Catalano O, et al. New developments in magneticresonanceimaging of the nailunit. J Rheumatol Suppl 2012;89:49-53
- Costa L, Caso F, D’Elia L, et al. Psoriatic arthritis is associated with increased arterial stiffness in the absence of known cardiovascular risk factors: a case control study. Clin Rheumatol 2012;31(4):711-15
- Scarpa R. New insights into the concept of psoriatic disease. J Rheumatol Suppl 2012;89:4-6
- Ritchlin C, Haas-Smith SA, Hicks D, et al. Patterns of cytokine production in psoriatic synovium. J Rheumatol 1998;25(8):1544-52
- Fiocco U, Accordi B, Martini V, et al. JAK/STAT/PKCδ molecular pathways in synovial fluid T lymphocytes reflect the in vivo T helper-17 expansion inpsoriatic arthritis. Immunol Res 2014;58(1):61-9
- Scarpa R, Atteno M, Lubrano E, et al. The effectiveness and safety of TNF-alpha blockers in the treatment of early psoriatic arthritis: an Italian multicentre longitudinal observational pilot study. Clin Rheumatol 2011;30(8):1063-7
- Fiocco U, Sfriso P, Oliviero F, et al. Blockade of intra-articular TNF in peripheral spondyloarthritis: its relevance to clinical scores, quantitative imaging and synovial fluid and synovial tissue biomarkers. Joint Bone Spine 2013;80(2):165-70
- McInnes IB, Kavanaugh A, Gottlieb AB, et al. on behalf of the PSUMMIT 1 Study Group. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet 2013;382(9894):780-9
- Song IH, Poddubnyy D. New treatment targets in ankylosing spondylitis and other spondyloarthritides. Curr Opin Rheumatol 2011;23:346-51
- Mease P, Genovese MC, Gladstein G, et al. Abatacept in the treatment of patients with psoriatic arthritis: results of a six-month, multicenter, randomized, double-blind, placebo-controlled, phase II trial. Arthritis Rheum 2011;63:939-48
- Ash Z, Gaujoux-Viala C, Gossec L, et al. A systematic literature review of drug therapies for the treatment of psoriatic arthritis: current evidence and meta-analysis informing the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2012;71(3):319-26
- Lories R, Vlam K. Tumor necrosis factor inhibitors in the treatment of psoriatic arthritis: a view on effectiveness, clinical practice and toxicity. Expert Opin Biol Ther 2014;14(12):1825-36
- Atteno M, Costa L, Matarese A, et al. The use of TNF-alpha blockers in psoriatic arthritis patients with latent tuberculosis infection. Clin Rheumatol 2014;33(4):543-7
- Costa L, Caso F, Atteno M, et al. Long-term safety of anti-TNF-alpha in PsA patients with concomitant HCV infection: a retrospective observational multicenter study on 15 patients. Clin Rheumatol 2014;33(2):273-6
- Costa L, Caso F, Atteno M, et al. Impact of 24-month treatment with etanercept, adalimumab, or methotrexate on metabolic syndrome components in a cohort of 210 psoriatic arthritis patients. Clin Rheumatol 2014;33(6):833-9