ORADE Report – Tristan Boyd, IFPA 2018 STOCKHOLM
I would like to thank the Ontario Rheumatology Association for giving me the opportunity to attend the 5th World Psoriasis & Psoriatic Arthritis Conference, which was held in Stockholm, June 27-30, 2018. This conference occurs once every three years and includes specialists from both dermatology and rheumatology, providing a unique cross-specialty forum.
The theme of this year’s conference was global challenges and future perspectives. Over the course of the meeting, available data for current treatment options were discussed and some of the unmet needs in psoriasis (PsO) and psoriatic arthritis (PsA) were addressed. This included a focus on education to enable earlier recognition and intervention in PsA, applying minimal disease activity (MDA) criteria in clinical practice – now available in the GRAPPA app – and treat-to-target strategies in routine patient care, as well as discussing some of the early successes of novel treatment options.
One of the keynote lectures given by Dr. Alice Gottlieb and Dr. Dafna Gladman showcased highlights from ‘15 years of biologic treatment of psoriasis and psoriatic arthritis – longterm efficacy and safety’. Despite tremendous progress in the treatment of PsA with advanced therapies, “at least 40% of patients do not respond to current therapies”. Thus, there is still an unmet need to identify novel mechanisms of action in patients who either do not respond or are treatment failures. Treatment of PsA is complicated by its heterogeneity and comorbid conditions that limit some available treatment options.
There was a large focus on educating healthcare providers on the importance of early recognition to shorten time to diagnosis and treatment. Defining ‘at-risk for PsA’ patients, based on skin phenotype, subclinical disease on imaging (US/MRI), family history, clinical biomarkers, and patient symptoms were discussed. There are ongoing efforts to help identify high-risk psoriasis patients for early intervention, with the relevance of a delay in diagnosis as little as 6 months being reiterated (i.e., erosion, joint deformity, functional impairment, etc.).
Once PsA is diagnosed, there are still unmet needs in optimizing disease management and ensuring a T2T strategy is being applied in clinical assessment. Dr. Peter Van de Kerkhof spoke about Treat to Target, but identified that a clear target has not been established in PsA. Certainly, the minimal disease activity (MDA) and very low disease activity (VLDA) criteria have taken hold, and are being used now in clinical practice to assist treatment decisions. Evaluating patients for comorbidities and improving multidisciplinary collaboration are areas that still need improvement.
There was an interesting Dermatology lecture, given by Dr. Mia Schneeweiss, about inverse psoriasis (iPsO) and its connection to PsA. iPsO affects 3-12% of patients with plaque PsO and is associated with a 40% increased risk of PsA versus those without. It is also associated with an increased risk of IBD compared with PsO without iPsO. Despite the significant burden of disease and impact on QoL associated with iPsO, it can be underreported and difficult to recognize, so awareness is important.
Dr. Laura Coates gave an update on current treatment guidelines for psoriasis and psoriatic arthritis. There is still no direct evidence for therapies in axial PsA; recommendations are based on axial SpA literature. A trial for ustekinumab was halted due to lack of efficacy, but TNFi and secukinumab are both approved for the treatment of axial disease.
The importance of lifestyle modification was addressed: obesity is associated with an increased risk of PsA. Weight loss helps achieve MDA in patients being treated with TNFi and also improves response to TNFi. Smoking is associated with worse PsA symptoms and poorer response to TNFi. These are 2 areas where patients can potentially improve their disease if properly educated and motivated. Lifestyle modification is also the only evidence based management for non-alcoholic fatty liver disease (NAFLD), which is increased in PsA patients.
Dr. Nehal Mehta from the NIH gave an interesting talk about PsO, PsA, and cardiovascular diseases. Psoriasis CVD is highly prevalent. Emerging data suggest the risk of CVD and metabolic diseases may be similar or even higher in PsA. Treatment of skin disease with biologic therapy may modulate coronary plaque characteristics. All psoriasis patients should get screening for CV risk factors at age 18 and then every 5 years thereafter (BP, BMI calculation, fasting glucose and cholesterol).
There was a lot of data presented on IL-17 and IL-23 inhibition in psoriatic disease:
- Secukinumab had reassuring data in pregnancy in psoriasis, psoriatic arthritis, and ankylosing spondylitis from the global safety data base (Warren RB, et al – P019): there was no evidence for increased rates of adverse pregnancy outcomes in psoriasis, PsA, and AS. The study was limited by short duration and drug exposure, but reassuring in cases where conception occurs while being treated treatment with secukinumab.
- Secukinumab showed sustained minimal disease activity (MDA) and remission related to DAPSA from a 2 year, phase 3 study (Coates LC, et al. – P047).
- Secukinumab showed improvements in all clinical, skin, and quality of life endpoints versus placebo, with 300 mg dosing associated with greater treatment effects versus 150 mg in anti-TNF-IR patients (Mease PJ, et al – P036).
- Secukinumab showed sustained efficacy in nail psoriasis at 2.5 years versus placebo – TRANSFIGURE study (Reich K, et al – P116), and sustained efficacy in moderate-to-severe palmoplantar psoriasis at 2.5 years – GESTURE study (Gottlieb AB, et al – P115).
- Ixekizumab demonstrated efficacy and safety over 3 years in patients with active PsA across skin and joint domains – SPIRIT-P1 and SPIRIT P-2 (Chandran V, et al – 34371).
- Data for risankizumab (IL-23 inhibitor) was shown in a 16-week, phase 3 study of patients with moderate-to-severe chronic plaque psoriasis, with efficacy demonstrated over placebo and ustekinumab (Blauvelt A, et al – 34401, 34395).
- IL-23 blockade in psoriatic disease with guselkumab showed promising phase II data at week 24 in terms of ACR20, 50, and 70, PASI70 and 90, as well as resolution of dactylitis and enthesitis.
- Guselkumab had faster response compared with adalimumab for the treatment of moderate-to-severe psoriasis in a 24-week, phase 3 RCT – VOYAGE 1 and VOYAGE 2 trials (Blauvelt A, et al – P045)
Thank you again to the ORA for the opportunity to attend this conference!
Dr. Tristan Boyd, MD, FRCPC
Assistant Professor, Division of Rheumatology, Department of Medicine