Experience of Tight Control in Psoriatic Arthritis Management within the Belfast Trust
A.Elliott, A.Quinn, D.Torrens, M.McHenry, A.Pendelton and G.Wright.
RVH Rheumatology Department, Belfast.
The development of scores in Rheumatoid Arthritis including ACR and DAS-28 led to an ability to monitor disease activity.
This led to treat to target studies and clinical guidelines including disease activity scores. TICORA was the first study to demonstrate tight control in RA leading to better clinical and radiographic outcomes compared to route care.
The lack of treatment targets and disease heterogeneity has made strategy trials in PSA more difficult.
In 2015 the first evaluation of tight control concepts in PSA was performed in the TICOPA paper assessing 206 DMARD naive PSA patients. Using the minimal disease Activity (MDA) criteria for PSA, patients were either assigned to a tight control (TC) startegy as per Figure 1 or standard care with percentage of patients acheiveing ACR 20 being the primary outcome. The paper was the first to demonstarte that a TC strategy achieved better outcomes for patients.
The concept of tight control has been evident from 2013 within the Belfast Trust.
After the TICOPA paper patients were referred for ‘tight control’ of their PSA.
The aim was to commence patients on DMARDs with a new diagnosis of PSA with review every 4 weeks with either the Nurse Specialist or Medical team.
The nurse specialist would perform baseline joint and skin scores along with other aspects of disease activity and treatment is then escalated as per the TICOPA paper. (See figure 1)
I sought to review those enrolled in the tight control strategy from 2014 and assess how treatment was escalted and what the outcomes at one year were.
I reviewed the notes of those PSA patients enrolled in the tight control strategy who had one year of data available within the Belfast Trust.
20 patients aged between between 21 and 70yrs who were all diagnosed by a consultant rheumatologist with PSA and referred for tight control within the Belfast trust were included in the review as they had one year data.
All patients were DMARD naive. All patients in the first 3 months were seen every 4 weeks and all patients at 6 months were seen at least every 6 weeks for review.
5 patients were commenced on Sulfasalazine (SLP) initially and 15 patients on methotrexate (MTX). No patients at any point in the review reached MDA if on SLP therapy. Three patients were escalated to biologics at 6 months and there was 10 out of 20 patients on biologic therapy by one year. Also overall at one year ACR 20 was achieved in 70% of cases and MDA in 50% matching up with results seen in the TICOPA paper.
Tight Control in Clinical Practise will yield results but is time consuming.
The main benefits are regular review to get on top of disease and patients feeling like they are not lost to system. The focus should be on achieving MDA on 2 occasions by escalating treatment to control disease and thinking about Biologic therapy early. If MDA is achieved then review can be stretched out after 24 weeks. Treatment strategies must obviously realate to patient’s goals.