ACR 2020: 14 New Things to Know About Psoriatic Arthritis

You can participate in research studies about arthritis by using our ArthritisPower app to join our patient-centered research registry.

The COVID-19 pandemic may have changed the format of this year’s annual medical meeting of the American College of Rheumatology — it was held completely virtually — but it did not disrupt the sharing of important research that directly impacts people living with psoriatic arthritis.

The CreakyJoints team combed through hundreds of studies, attended sessions from top psoriatic arthritis experts, and asked our team of patient and physician advisors to share the updates they deemed most important.

We curated this guide to psoriatic arthritis research and trends from ACR that you should be aware of.

For more research breakthroughs from ACR Convergence 2020, check out our main guide: ACR 2020: 100+ Arthritis and Rheumatic Disease Updates Patients Must Know About.

1. Clinical trials are leading toward more personalized medicine in psoriatic arthritis

With advances in targeted therapies for psoriatic arthritis — multiple biologics as well as more oral pills on the way — “the challenge for clinicians is how to use them,” said rheumatologist Arthur Kavanaugh, MD, Director of the Center for Innovative Therapy in the Division of Rheumatology, Allergy, and Immunology at the University of California at San Diego during an ACR presentation.

Dr. Kavanagh discussed some recent head-to-head trials — in which one medication is directly compared to another — noting that this kind of research is the best way to figure out which therapies work best for which patients, reported Healio Rheumatology.

For example, in one study where the IL-17 inhibitor ixekizumab (Taltz) was compared with the TNF inhibitor adalimumab (Humira), “ixekizumab demonstrated superiority that was driven by skin response.”

Dr. Kavanaugh said that doctors need to look at which “psoriatic arthritis domains” are most important to their patient. Over time, medications will be tailored toward optimizing specific PsA domains, such as skin symptoms, axial (spine) pain, enthesitis, and more.

2. The JAK inhibitor upadacitinib (Rinvoq) is doing well for psoriatic arthritis

Already approved to treat rheumatoid arthritis, the new JAK inhibitor upadacitinib is currently being studied in other inflammatory arthritis, including psoriatic arthritis and axial spondyloarthritis. Data presented at ACR found that daily doses (either 15 or 30 mg) improved musculoskeletal symptoms, psoriasis, physical function, pain, fatigue, and radiographic progression in people with PsA.

In the phase 3 trial — the last phase before seeking FDA approval — 1,705 participants were randomized to receive either 15 mg upadacitinib daily, 30 mg upadacitinib daily, or 40 mg of adalimumab (Humira) every other week or placebo for 12 weeks. Patients already had a poor response or intolerance to at least one non-biologic disease-modifying drug.

The study used a primary endpoint called ACR20, which means a 20 percent improvement in joint pain. It was met by 71 percent of people taking the 15 mg dose of upadacitinib and by 79 percent of people taking the 30 mg dose, compared with 36 percent of people on a placebo and 65 percent of those taking adalimumab. Patients on upadacitinib also had improvements in physical function and skin clearance compared with placebo.

“Upadacitinib 15 mg and 30 mg demonstrate superior efficacy compared to placebo in treating psoriatic arthritis symptoms and signs in patients refractory to prior non-biologic DMARD therapy,” said Iain McInnes, MD, President of EULAR and Director of the Institute of Infection, Immunity and Inflammation at the University of Glasgow, in Scotland, as reported by Healio Rheumatology.

3. There was more good news for treating PsA with IL-23 medication

Interleukin-23 (IL-23) is an inflammatory protein that plays a role in psoriasis and psoriatic arthritis. Earlier this year, the biologic guselkumab (Tremfya) that inhibits IL-23 was FDA-approved for psoriatic arthritis. (It had already been approved to treat psoriasis.)

One study presented at ACR was a meta-analysis (a study that analyzes the results of other studies) of clinical trials for a large number of psoriatic arthritis treatments. It aimed to compare how guselkumab’s results would fit in. The researchers looked at a number of different outcomes, such as improvements in joint pain, skin clearance, function and disability, and more. They found that guselkumab was considered better than most other targeted treatments when it came to improving skin symptoms and was comparable to most other targeted treatments for joint symptoms, physical function, and safety.

Separate research showed that guselkumab specifically helped improve axial (spine/back pain) symptoms in people with PsA. Researchers followed people with sacroiliitis (inflammation of the sacroiliac joints, where the spine meets the pelvis) for a year and found that those who were treated with guselkumab were able to maintain improvements in back pain through one year compared with people taking a placebo.

What’s interesting about this finding, says Boston University rheumatologist Jean Liew, MD, is that a different medication that inhibits IL-23 — called ustekinumab (Stelara) — has not worked well in past clinical trials for axial symptoms.

Ustekinumab, which is approved for psoriasis, psoriatic arthritis, and inflammatory bowel diseases like Crohn’s and ulcerative colitis, works in a slightly different way from guselkumab. The difference in impact on spine symptoms “may be due to the different pathways being involved,” says Dr. Liew. This finding adds another wrinkle to the story about which therapies work best for which specific symptoms.

4. A new type of PsA medication showed promise in a preliminary trial 

The drug is called deucravacitinib and it’s considered a TK2 inhibitor. A cousin of JAK inhibitors, it’s an oral pill that acts on a specific immune system pathway to tamp down inflammation. The medication has been previously studied for psoriasis.

A study showed that, after 16 weeks, 53 percent of people receiving a 6 mg/day dose and 63 percent of people receiving a 12 mg/day met response criteria (a 20 percent improvement in symptoms, known as the ACR20), compared to just 32 percent of people who were on a placebo medication.

ACR50 responses (a 50 percent improvement in symptoms) were seen in 11 percent of the placebo group compared with 24 percent of those taking the 6 mg dose and 33 percent of those taking 12 mg.

Northwestern University rheumatologist Eric Ruderman, MD, discussed the trial results on RheumNow, saying they indicate that the medication is effective, but questioned whether it will ultimately be shown to work that much better than existing therapies, such as biologics that inhibit the inflammatory protein IL-23.

The results are from a phase 2 trial, which means the medication still needs more investigation in larger groups of patients before it can seek approval from the U.S. Food and Drug Administration (FDA). The current study included about 200 patients.

5. Carotid artery ultrasounds may help better identify heart disease risks in psoriatic patients

People with psoriatic disease have an increased risk of cardiovascular disease that is driven both by comorbidities (like obesity and diabetes) as well as inflammation and other issues directly related to the psoriatic condition itself. It’s thought that people with PsA first develop “subclinical atherosclerosis” — clogged arteries that do not cause symptoms. Detecting these changes early could help doctors and patients better manage heart disease risk factors.

A study from a team of researchers from Mexico found that using a non-invasive ultrasound to measure the thickness of the carotid artery in the neck could help better identify PsA patients with cardiovascular risk factors. Researchers conducted ultrasounds on 69 PsA patients and 69 controls who were matched for age and comorbidities, but did not have PsA. They found there as was a greater prevalence of thickness of the carotid artery and more plaque in people with PsA than in the control group.

The researchers concluded that “patients with psoriatic arthritis have a higher cardiovascular risk, as proven by the increased cIMT found on carotid ultrasound results” and that it is “opportune to perform a carotid ultrasound in patients with PsA to attain an optimal management of the disease.”

6. Ultrasounds could help differentiate psoriatic patients who also have fibromyalgia 

When people with inflammatory arthritis also have fibromyalgia (which is common), the inflammatory arthritis can be harder to treat and manage. Thus, it’s important to know when fibromyalgia may be contributing to hard-to-treat symptoms rather than the inflammatory arthritis. A team of Israeli and Canadian researchers did full-body ultrasounds on 156 psoriatic arthritis patients — including joints, tendons, and entheses — looking for signs of inflammation of the joint fluid (synovitis), around the tendons (tendosynovitis), and of the entheses (enthesitis). The patients also completed surveys about their symptoms, which helped classify them as having or not having fibromyalgia.

The researchers found that while people with fibro and PsA had worse scores on clinical measures of pain compared to PsA patients without fibro, the ultrasound results were similar between the two groups.

The researchers believe their results show that ultrasounds have “significant additional value” in assessing disease activity in PsA patients with fibromyalgia. This could help doctors figure out how to tailor treatments for people who have both conditions.

 7. ‘Residual’ symptoms of PsA are common in people who are deemed to be in very low disease activity

Many PsA patients know that just because you’re considered to be in low disease activity doesn’t mean you feel well. Now data from a team of researchers at the University of Pennsylvania, New York University, Northwestern University, the University of Utah, and the Cleveland Clinic demonstrates this. Researchers surveyed 244 PsA patients who started a new PsA therapy and completed a series of questionnaires about their symptoms. Doctors assessed disease activity with counts of swollen and tender joints as well as assessing enthesitis (inflammation where tendons and ligaments meet bone, such as at the Achilles heel).

The researchers found that 47 percent of people who were considered by their doctors to be in very low disease activity had at least one residual symptom, compared to 85 percent of people who were not considered to be in low disease activity who had at least one residual symptom. The most common lingering symptoms were fatigue, spine pain, peripheral joint pain/swelling, stiffness, disrupted sleep, and tenderness to touch.

More than 10 percent of people with very low disease activity reported difficulty with daily function, work, and skin symptoms.

This study shows that “despite effective therapy, many patients continue to have active symptoms,” says study coauthor and rheumatologist Alexis Ogdie, MD, Associate Professor of Medicine at the Hospital of the University of Pennsylvania.

The researchers concluded that “further studies are needed to develop comprehensive, evidence-based, patient-focused treatment plans to address these residual symptoms.”

8. PsA patients and providers have different perspectives on the prevalence of fatigue

Ask anyone with psoriatic arthritis about fatigue, and they’ll likely share that it is a huge burden. Many PsA patients consider fatigue as big or bigger a problem than joint pain or skin plaques. An interesting study asked a group of international PSA patients and their providers (932 pairs in all) to fill out surveys about different aspects of their disease. Patients completed surveys on fatigue, work productivity, disability, and more. Doctors answered questions about their patients’ disease and whether or not the patients had fatigue.

They found that while 81 percent of patients reported fatigue, only 28 percent of providers said their patients had fatigue.

Researchers, led by rheumatologist Jessica Walsh, MD, Instructor at the University of Utah School of Medicine and George E. Wahlen Veteran Affairs Medical Center, concluded that such discrepancies “between patient and physician reports of fatigue suggest that physicians may not be aware of the extent to which patients experience fatigue.”

9. PsA patients and providers also have different perspectives on the prevalence of anxiety and depression

Some of the same researchers conducted a similar study seeking to understand whether patients and providers report comparable rates of mental health issues like anxiety and depression in psoriatic arthritis patients. After collecting data on 688 patient-physician pairs, they found that doctors reported anxiety and/or depression in 14 percent of patients, but 37 percent of patients self-reported anxiety or depression.

It also seems that doctors may not be aware of the degree to which PsA patients are struggling with anxiety and/or depression.

10. A majority of PsA patients have an ‘unacceptable’ level of disease activity, which is linked with more depression and challenges with social activities 

Although treatments for psoriatic arthritis have proliferated in recent years, many people do not achieve remission. Having ongoing disease activity takes a toll on many different aspects of patients’ lives, including an association with more depression and challenges with social interactions.

Researchers, led by Dr. Ogdie, sought to understand patient perceptions around “unacceptable” symptoms, according to a survey called the PsAID9, which asks about pain, fatigue, skin problems, work and leisure activities, sleep disturbance, and more. A survey was completed by 1,570 members of the National Psoriasis Foundation.

Of those who had a self-reported diagnosis of PsA and completed the PsAID, 60 percent reported an unacceptable level of disease activity. Having unacceptable disease activity was also associated with depression and challenges participating in social activities.

The good news was that “being monitored by a dermatologist or rheumatologist was associated with an increased likelihood of being in a patient acceptable symptom state,” the researchers found.

11. There’s an increased focus on identifying people with psoriasis at an increased risk of developing psoriatic arthritis

Identifying people with psoriasis who, for various reasons, could be at increased risk of developing psoriatic arthritis could provide a unique opportunity to implement preventive strategies to thwart that progression. This could include treating psoriasis more aggressively with medication and/or making lifestyle changes, such as losing weight if needed.

More research is needed to understand how progression from psoriasis to psoriatic arthritis can be stopped, but in order to do that research, there must be agreement on which kinds of patients are at an increased risk.

So a team of psoriatic experts has been studying how to classify and identify such “pre-clinical” PsA patients. In research presented at ACR, they shared some risk factors in psoriasis patients that they agreed are linked to an increased risk of PsA:

• Obesity
• Presence of arthralgia (joint pain)
• Severe psoriasis
• History of uveitis (eye inflammation)
• Nail psoriasis
• Scalp psoriasis
• First-degree relative with psoriatic arthritis

12. Delays in getting diagnosed with psoriatic arthritis are common, even in people with joint pain symptoms 

Researchers led by Paras Karmacharya, MD, a rheumatologist at the Mayo Clinic College of Medicine in Rochester, Minnesota, analyzed data on 162 people who were diagnosed with psoriatic arthritis between 2000 and 2017. They found that it took more than two years from the time joint pain symptoms started for people with psoriatic arthritis (PsA) to be diagnosed with this condition.

People who were under age 40 when symptoms began, those with a higher body mass index (BMI), and those with enthesitis (inflammation in the spot where ligaments attach to bones) were more likely to experience a delay in diagnosis. Read more here about the findings.

13. Looking at patients’ medical histories before they get diagnosed with psoriatic arthritis could provide clues that accelerate diagnosis for others

What kind of health care journey do patients follow on the route to getting diagnosed with PsA? Researchers looked at a large insurance claims database to better understand the kinds of medical codes that were logged in the six years prior to people being diagnosed with psoriatic arthritis, comparing 13,661 people who ultimately got diagnosed with PsA with controls who were not diagnosed with PSA.

They found that people who were ultimately diagnosed with PsA were more likely to have a code for psoriasis (60 percent compared to 2 percent of controls) in their medical record. People who were ultimately diagnosed with PsA but did not have a prior code for psoriasis were more likely to have been codes for other forms of arthritis, such as osteoarthritis or rheumatoid arthritis, suggesting this is an area where misdiagnosis is common.

As patients got closer to getting diagnosed with PsA, codes for enthesitis, back pain, and psoriasis became more common, which indicates these are PsA clues doctors and patients should pay attention to. 

Researchers also observed that the type of provider patients saw had a big impact on their pre-PsA diagnoses. Dermatologists were less likely than other providers to enter codes for arthritis and musculoskeletal issues, while rheumatologists were unlikely to code for psoriasis but had a fairly even distribution across different types of arthritis. 

In the end, PsA was most commonly diagnosed by rheumatologists (40 percent) but was diagnosed in 22 percent and 7 percent of cases by general practitioners and dermatologists, respectively.

14. A smartphone app could help diagnose psoriatic arthritis in remote settings

A preliminary study is investigating whether smartphone technology could assist doctors in diagnosing conditions like psoriatic arthritis in telehealth settings.

An app being developed incorporates sensor-based measurement tools that could measure changes in certain aspects of psoriatic arthritis symptoms. For example, the app uses a gyroscope to measure arm rotation and what happens when a user opens a jar. It measures users’ gaits while walking to look for problems with symmetry. It takes pictures of fingers and toes to check for symptoms like dactylitis (or swelling of the digit such that it resembles a sausage).

Researchers are currently testing the app in people with PsA and healthy controls to how the app records different results in people with PsA and without, and whether these differences are significant enough to predict PsA symptoms in people who are not yet diagnosed. Initial results suggest that the measurements so far can distinguish some features of PsA, but testing a bigger group of patients is needed.

The authors note that if ultimately validated, “these and other tools may provide for remote self-assessment when clinical visits cannot be performed.” Such technology could also help study disease progression and assess patients’ response to treatment.

You Can Participate in Psoriatic Arthritis Research Too

If you are diagnosed with psoriatic arthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining CreakyJoints’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centered research registry for joint, bone, and inflammatory skin conditions. Learn more and sign up here.