Minimal Disease Activity as Alternate Target in PsA

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This is ReachMD. Welcome to this special series, Beyond Skin Deep: Impacts of Psoriatic Arthritis, sponsored by Lilly.

Dr. Volkmann:
Absolute clinical remission by its most strict definition may be difficult to achieve for some patients.  Therefore, many providers adopt a minimal or low disease activity approach as an alternate target for treatment.  There are no universally accepted or validated definitions of what low disease activity and remission are for psoriatic arthritis, but some researchers have proposed the following criteria:  So, example, one approach is a patient would achieve minimal disease activity when 5 of the 7 criteria are met.  So there are 7 criteria, and if they met 5 of these, then this would be considered low or minimal disease activity.  So the first one is a tender joint count less than or equal to 1.  The second is a swollen joint count less than or equal to 1.  The third is a Psoriasis Area and Severity Index less than or equal to 1 or a body surface area less than or equal to 3%, so this is the extent of their psoriasis on their skin.  The fourth is a Patient Pain Visual Analog Scale less than or equal to 15, so this is a measure where a patient on a line draws a marking based on the extent of their pain.  The fourth [sic] would be a Patient Global Disease Activity Visual Analog Scale less than or equal to 20, so again, another Visual Analog Scale where it’s a line, where instead of patient rating their pain, they’re rating their overall feeling of their disease activity.  So these are both subjective measures of the patient’s pain and disease activity.  The next one is the Health Assessment Questionnaire Disability Index of less than or equal to 0.5.  This is a questionnaire that we use in a lot of different diseases in rheumatology to assess the patient’s health-related quality of life and function and disability.  And then the final is tender points at points where there are insertions into joints, and this would be less than or equal to 1. 

Now, of note, that this type of approach doesn’t include any kind of blood levels, such as inflammatory markers.  It’s purely based on the physical exam and then the patient’s subjective feeling of how they’re doing.

So my practice—and every provider may be a little bit different in this area—but my practice is to combine both patient-centered measures, such as the questionnaires I just described above, along with physical examination findings, such as the tender or swollen joints on exam, and then also combining some kind of laboratory measures, such as an inflammatory marker such as the C-reactive protein or the sedimentation rate.  With some exception I think that all of these should be evaluated at a minimum of every 3 months.  This is generally when we see patients who are on medication to assess for safety and toxicity of the medications they’re taking, and it’s also a good time to reassess disease activity, so for most patients it should be at a minimum of every 3 months.

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