ACR24 - PSORIATIC ARTHRITIS Save

Hi, everyone. Jack Cush. I'm on the floor of the ACR Exhibit Hall. It's ACR convergence twenty twenty four. We're in Washington DC.

This is day one, morning one. We're excited to be here. Looks like a lively meeting. Lots of folks, lots of buzz. The exhibit floor and our booth is really happening.

If you're here at the meeting, come by, visit us. We'd love to meet you. Say hello. Give you one of the new RheumNow pens. Hope you like that.

I want to talk to you about what I think you should be doing and what's new at this meeting. You know, the meeting is is really the same meeting. Right? It's face to face and that's what people want. Some things are new.

And we have the same old sessions, the great debate. This morning they had the year in review. We're going to have knowledge bowl and other highlights including the wrap up at the end. But plenary sessions are have flipped. They're in the morning at 09:00 and the posters are beginning right about now at 10:30.

So that's something that's new. I think for you watching this video, how am I gonna learn the ACR? I'm gonna give you a few pointers that I think you should pay attention to. Number one, come to the meeting. See us at the booth.

Go to your favorite sessions. Number two, if you're at home, I'd recommend that you follow us on Twitter. On Twitter, you're going to get this constant stream of information and what's happening really right to the minute. And it's almost like watching a ticker tape of what's going on at the meeting. I think that's kind of exciting, but maybe you're not a Twitter person.

And maybe you wanna get a feel for what happened at the meeting. I'm gonna give you three ways that you can do that. Number one, that is at the end of every day at 6PM eastern time. We're gonna live stream the daily recap where it's gonna be me and three or four of the faculty, and we're gonna review the happenings of that day and what was notable, exciting, and something you wanna take home. Number two, starting next week when you get home, you can view the video that's gonna be called the lupus topic panel or the RA topic panel or the PSA.

We have topic panels with me and four experts in lupus, RA, etcetera. And we're gonna do RA PSA SPA, lupus, JAK inhibitors, tick inhibitors, and IL seventeen drugs. And so that's like six different videos that you'll be able to look at. And the third way that makes the most amount of sense is this go to the RheumNow website and you might already subscribe and get a daily email or a weekly email. But if you're an RA person or a lupus person, we have an email list and you could sign up, check the box.

I want the topic email list that'll come out once a week. And if you check the box on whatever topic you like, you're gonna get an email after ACR and all the lupus stuff that we produce. So you'll have that in your inbox to review. By the way, everything I just said that's in video form will also be in podcast form. You can listen to the daily recap podcast.

You can listen to the topic panels in a in a podcast. And you can also listen to podcast accumulated podcast reports from all our faculty who are here covering the meeting for you. Hope you enjoy this meeting. I'm going to. We'll talk more.

Hi. My name is Akhil Sood. I'm reporting for RheumNow here in Washington DC. Today I want to talk to you about a premilast in psoriatic arthritis. Suppose you're seeing a patient with psoriatic arthritis for follow-up.

Overall, they're doing great with no signs of active disease. But they mentioned they're having low back stiffness and some joint pain and some stiffness in their hands and feet. What do you do next? Sure, NSAIDs may be the answer, but it carries side effects. What about apremolast?

At ACR, are a few abstracts that highlight the potential benefits of apremelast in psoriatic arthritis. Abstract fourteen sixty six, in the FOREMOSS trial, looked at patients with early PSA, specifically those with early osteoarthritis. They found that apremelast was associated with significant improvement in tendon joints and swollen joints, and there was an improvement in patient reported outcome measures. Then, Abstract 25.83 found that apremelast not only helps the joints, but also helps the spine. They found at weeks twenty four and forty eight, there were significant reductions in axial inflammation on the MRI.

And here's a surprising benefit: epremelast may even have metabolic benefits. In Abject May, patients treated with Epremelast per year had significant reductions in their body fat on DEXA scan, and this was linked to improvements in disease activity. This suggests that PRIMROS might help more than just the joints and the spine, but also have metabolic advantages as well. So the benefits seem great, but are there any risks? Abstract 2640 highlight that the increased risk of serous infection was higher among patients on a prevelast in a biologic or targeted, DMARC.

But it's important to note we don't know the underlying factors that may contribute to this increased risk. So back to our patient. Should you add a Permalast? Ultimately, it's about shared decision making. While it's important to weigh the risk and the benefits, it's also important to consider the patient preferences.

For some patients, lifestyle changes like diet and physical activity may be the preferred route. On the other hand, some patients may prefer a quicker response and improvement in their joints, spine, and other benefits, and a premise may be the answer. Either way, it's about creating a plan that fits their needs and preferences. My name is I can see you reporting for me now. Thank you.

This is Catherine Bakewell. I'm reporting to you today, 11/18/2024 on the best thing that I saw today in psoriatic arthritis at ACR. Today, I'm actually gonna take you on a rapid fire tour of several different abstracts I found really exciting. I want to start with this one which is two five eight three and it's entitled Epremelast Reduces Axial Inflammation in Patients with Psoriatic Arthritis as Assessed by Candon MRI Scoring results from a phase four study. So what is very exciting about this trial is that a premilast has not been considered effective for axial disease.

It's one of the things that we say absolutely new in ankylosing spondylitis And we're considering it now, though, as potentially effective in axial psoriatic arthritis because of the results of this phase four trial that demonstrated by the CANDON MRI scoring system, which is a very detailed anatomy based comprehensive scoring system for inflammatory lesions, pardon me, both at the vertebral bodies and at the posterolateral elements, demonstrated significantly reduced inflammation versus placebo at both twenty four and forty eight weeks. So this may change the way that we think about a premelast in this domain. The next abstract I want to highlight is this 2584, is looking at a new agent, ZazocitinibTAC-two seventy nine, an oral selective TYK2 inhibitor, and it's entitled Achievement of Remission and Additional Improvements in Disease Activity in Patients with Psoriatic enrolled in this phase two b trial. This element or this new novel agent, this tac two seventy nine, did demonstrate higher rates of remission and low disease activity as assessed by both dabza, dabza, PASDAS, and dash twenty eight CRP at twelve weeks, and we'll move forward now to phase three. So excited to see more on that.

The next one is twenty five eighty two, which is efficacy and safety of sonolocumab, a novel a novel IL seventeen ANF nanobody. These are the little bitty tiny antibodies potentially with better tissue penetration and lower vascular areas like the enthesis. This was, active psoriatic arthritis, twenty four week results from a global randomized double blind, controlled phase two trial. This is Ian McGinnis, and it had very nice looking results with ACR fifty scores up in the sixty percent at twenty four weeks, which again is not normally what we see. No unexpected safety signals, again, moving forward to phase three trials.

Fantastic. Next abstract is going to be 2638, defining sonographic enthesitis in psoriatic arthritis, developing a data and expert driven diagnostic criteria for the inflammatory enthesitis at the single enthesus level. This is Andre Riviera. What I can tell you about this trial is that they were dialing down on what increases experts said, like, confidence that what they are looking at ultrasonographically represents enthesitis in a spondyloarthritis, and the results were that a two plus power Doppler very important or four or more elementary lesions so that would be hypoechogenicity plus thickening plus enthesophyte plus Doppler one plus for example. Enthesophyte is not specific seen in the healthy So the heel spurs, as we all know, it's not going give you a diagnosis of spondyloarthritis.

Last abstract for you today, 2635. This is Doctor. Jessica Walsh's group out of the University of Utah. Direct to patient screening for psoriatic arthritis patients with psoriasis. Pardon me, I'm going to redo that.

26.35 direct to patient screening psoriatic arthritis in patients with psoriasis appropriateness of rheumatology referrals and treatment outcomes. This is important because she mailed out surveys to patients with a psoriasis diagnosis, asked them to undergo the PEST screening questionnaire, and they self referred to rheumatology for a positive PEST screening questionnaire. About a third of patients got a new psoriatic arthritis, really underscoring how exciting this is as a method of finding these psoriatic arthritis patients in the community. So with that, that's all I have for you today. Thank you for your time and attention.

Hi, this is Eric Dine from RheumNow here in Washington, D. C. For today's first day of the ACR convergence. One of the big topics of conversation has been bimekizumab, and I'm honored to be here with Doctor. Anna Maria Orbi of the Johns Hopkins Arthritis Group.

Tell me about Abstract 600 and what we learned about bimekizumab.

First of all, thank you Eric, an honor as well. So our abstract analyzed long term effects of pimekizumab on psoriatic arthritis life impact in people with psoriatic arthritis using the PSA12 patient reported outcome measure. Pimekizumab, as we know, is a selective dual inhibitor, it's looking 17 ANF, and it is labeled for psoriatic arthritis. The B OPTIMAL and B COMPLETE are randomized controlled trials, phase three trials of Rheumatuzumab in TNF naive and TNF experienced patients respectively. And we are looking at the long term extension for these trials.

Now, about PISA-twelve, it's a patient reported outcome measure that is validated in multiple languages and it is a composite scores of pain, physical function, sleep, emotional well-being, pain domains and it has a score range of zero to 10. A difference of three is a meaningful improvement at patient level and the score of one is almost no symptoms or life impact, whereas a score of two is a low level And these would be desired targets in our patients. So, with bimekizumab, half of the patients, whether they were TNF naive or TNF experienced, achieved no to low disease impact in these clinical trials. And this was maintained at one year in the clinical trial, as well as our longest data go as far as two years, where patients maintain these states. And I think that this is very important because life impact is related and a determinant of achieving and maintaining treatment targets in psoriatic arthritis.

Yeah, and it's really the things that the patients want to hear the most is the things how they experience and not necessarily those objective numbers that we're always following in the office. That's great when we have those patient reported outcomes. That's wonderful. I think that's a great study. Thank you very much.

I appreciate you sharing your abstract with us today.

My pleasure. Thank you.

Hello. I'm Medela Castro at ACR twenty twenty four in Washington, D. C. And I want to talk to you about monotherapy versus combination with conventional DMARDs in psoriatic arthritis patients. I want to start with an abstract number five eighty four that evaluated the effectiveness of tofacitinib versus monotherapy versus combination therapy with other conventional DMARDs in patients with psoriatic arthritis.

For this study, they included the data of patients from the core Avedas registry for psoriatic arthritis. In the total of the study population here was one hundred and forty one patients with psoriatic arthritis, out of which forty six percent of these patients were on tofacitinib monotherapy. There was no statistical significance between the effectivity of this medication monotherapy versus combination with conventional DMARC in psoriatic arthritis patients. It was very interesting that it seemed that patients that were on monotherapy, where they stayed longer on this medication compared with the ones that were on combination with DMART. On that same note, abstract five ninety five evaluated the drug survival of combination with conventional DMARDs, predominantly methotrexate, in patients with psoriatic arthritis.

In this study, this was actually a large systematic review and meta analysis of 19 studies that involved over twenty eight thousand patients with psoriatic arthritis. Interestingly, which I think is also limitation of this study, all of the studies were observational and only two of them, included non TNF, biologics. In this study, it did show that methotrexate, particularly in combination with TNF inhibitors, seemed to improve the drug survival in patients with management with psoriatic arthritis. For more information, stay tuned at RheumNow.

I'm Richard Conway reporting for RheumNow from ACR twenty twenty four. And today, I'm going to talk to you about an abstract presented in Sunday's poster session. This was by Mark Gibson and colleagues from King's College London. It's abstract number nine eighty nine. So this was a Bayesian network meta analysis.

And I know a few people have already glazed over that combination of words, but I'm going to try and keep it real simple for everyone. And we'll try not to get too bogged down in the details. But I think it's an important and provocative study that's being presented. So this was looking at malignancy. And it was looking at JAK inhibitors, TNF inhibitors, and patients on placebo, and trying to compare those different groups.

It was across inflammatory diseases. So there's patients with rheumatoid arthritis, with psoriatic arthritis, with psoriasis, with inflammatory bowel disease, and axial spondyloarthritis. They included 196 studies. So this is a large meta analysis. They had over one hundred and twenty thousand patients and one hundred and thirty thousand patient years of exposure.

There were sixty eight thousand patient years of exposure to JAK inhibitors, 56,000 to TNF inhibitors, and ten thousand to placebo. During this, they saw just over one thousand malignancies when they excluded non melanoma skin cancer. So this is other malignancies. Now, it said it's a Bayesian network meta analysis sort of figures they report as a log ratio, which is we're not used to looking at that. It's confusing to us.

So I'm not going to get too bogged down in it. If you want to go check out the poster, please do for those finer details. But I'll just stick to the bottom line of what they found, because I think it's very interesting. So they found that TNF inhibitors had a significantly lower risk of malignancy than JAK inhibitors. So we expect this given oral surveillance.

So this kind of fits with our priors. But then it got really interesting. So TNF inhibitors compared to placebo have a significantly lower risk of malignancy. JAK inhibitors compared to placebo seem similar for any type of cancer. And JAK inhibitors seem to have a lower risk than placebo for hematological malignancies.

So this is a very provocative study, I would say. It's kind of jiving with what some of us have been saying about oral surveillance, that maybe it's not that the JAKs are bad, it's that the TNFs are good at preventing malignancy. It's one meta analysis. We can't place too much weight in it, but I think it's a very, very interesting one. So I'm Richard Conway.

You can follow me on Twitter at RichardPaconway. Remember to tune into RheumNow for all the best coverage from ACR twenty twenty four.

My name is Doctor. Philip Meese. I'm a rheumatologist from Seattle, Washington and Director of Rheumatology Research at Providence Swedish Medical Center in that city. I'm delighted, to report on an abstract about bimekizumab. Bimekizumab is an IL-17A and F inhibitor that has been approved in the treatment of psoriasis in The United States and has recently been approved for the treatment of psoriatic arthritis and axial spondyloarthritis.

This abstract reported on two major patient reported outcomes that are of great importance to patients. One, of course, is pain, but the other is fatigue. Fatigue ends up being a big deal to our patients, partly because it is a phenomenon that occurs in an increased amount in inflammatory diseases and it has central brain mechanisms, and can be improved by treatment of the underlying, immune disease. And thus, we saw both in pain and fatigue very significant improvements in the both biologic naive population or B optimal and the B complete trial, which is in bio experienced patients. So for example, improvement in pain.

One of the ways in which pain results are reported in the pain literature are 30% or 50% improvement in pain. 30% being something that the patients can tell and is meaningful and 50% being a really significant improvement in pain. And what was shown was that about sixty percent of the patients achieved an MCID, of pain and about forty percent had this really substantial, benefit. We know that this is a highly important outcome for patients and showing, that the majority of patients did achieve this is is great. In terms of, fatigue, there was an instrument known as the facet that was used to measure this.

It has several questions. It's a composite measure. And there too, we found that a highly important improvement in fatigue occurred in at least fifty percent of patients. And this was sustained over time, over the course of two years, as was the sustainment of of pain response, suggesting that not only, was there a substantial effect that occurred relatively quickly, but it was durable. It it lasted over time.

Plus, this gives us important information to support the use of an IL-17A and TAP inhibitor in achieving goals that are very important to patients, improvement of pain and fatigue. Hi, my name is Doctor. Philip Meese. I'm a rheumatologist in Seattle, Washington and direct the Rheumatology Research Division of the Providence Swedish Medical Center there. I'm very glad to present data from an abstract on integrated safety across all of the trials of bimekizumab in axial spondyloarthritis and psoriatic arthritis.

These were all the 2B and phase three studies as well. So it gives us a very comprehensive picture of, patient safety in over 1,500 patients observed for up to two years. What we saw were relatively low rates of infection, about one point three or one point four events per 100 patient years in both the axSpA and PSA studies. We saw relatively low rates of candida infection. This is something of interest because we know that IL-seventeen as a cytokine protects us from surface candida.

So there were occasional cases of thrush, for example, usually just occurring once and easily treatable with topical treatments for the most part. Only occasionally were we to see patients with recurrent episodes, more than one. So this rate was also low and there were no systemic fungal infections noted nor any cases of tuberculosis. Another area of interest is inflammatory bowel disease. This was seen in very low rates in the axial spondyloarthritis population, slightly more than the psoriatic arthritis population.

Again, this is something that we have seen with this mechanism of IL-seventeen inhibition. Usually these are cases in patients who have a past history of inflammatory bowel disease and there's a flare. Occasionally we have seen some new onset cases. So this happens, the frequency is low, we do need to talk to our patients about it. Another issue that is, being monitored for in current trials of psoriasis and psoriatic arthritis is the issue of depression and suicidal ideation because these are issues that are more prevalent in a patient population with these diseases.

Again, here the rates were low. There were slightly more patients in the bimekizumab arm that reported let me start that one again. Again, these rates were low, and I think if anything, what this reminds us to do is to talk to our patients about their mood, to talk about depression depression openly, and be ready to care for this issue if the patient is meaningfully, depressed or has potential suicidal ideation. Another issue that is of interest, especially in a group of patients who have a proclivity to obesity, is the potential for liver transaminase changes because sometimes if a patient has underlying fatty liver or is on methotrexate, we may see perturbations in LFTs. This was seen on occasion, so we do occasionally see upticks in, liver transaminases, but these were generally transient and would return to normal and generally did not lead to any concern about the ongoing use of bimekizumab.

Another topic of interest is that of uveitis. We know, for example, that when we use a monoclonal TNF antibody that we can see reduction in uveitis flares, which can occur in patients with PSA or Axial SpA. The rates of uveitis in this integrated safety analysis were quite low, and so it doesn't look like there's, in any case, a significant increase in number of cases of uveitis, and overall the rates were very low. We saw no signal, for malignancy, no signal, for, cardiovascular disease of concern. So in general, this report, underlines the relative safety and tolerability of bimekizumab and IL-17A and F inhibitor, a dual mechanism that has been recently approved for the treatment of psoriatic arthritis and the full spectrum of axial spondyloarthritis.

Hi, this is Arti Kavanagh coming to you from ACR Convergence twenty twenty four, and here we are in DC. Very pleased to be here. The meeting is just getting started. A lot of abstract to be presented. The posters are out today.

A lot of things in psoriatic arthritis about which I'm very interested. This morning though, there was a session which I think is really relevant to psoriatic arthritis and to other rheumatic diseases, that was about weight loss and specifically the weight loss drugs. They reviewed particularly the SGL-two and GLP-one related mechanisms. A lot of exciting data on there. Weight loss, improvement in disease outcomes, and we've seen that published now.

This is critically important in psoriatic arthritis, where we know the negative impacts of comorbidity, including the metabolic syndrome. In the session, they also went over the cardiorenal axis, which is part of the new consideration for the metabolic syndrome and how these medications particularly can improve that. A little bit of a downside that was shown was that when the patients stop these medications, they really lose a lot of benefit that they had had. So it may be that you need to persist on these medicines, although it was raised that maybe you could potentially taper the medicines. If it's every week, cut that to every ten days or so to still hopefully maintain some of the benefit.

The treatments may also, in addition to helping weight loss, which is very important, may have an anti inflammatory property. So this was kind of an intro. We don't have a ton of posters that are addressing this, but they're coming. There's a lot of interesting studies, and the one thing that I found amazing was that it's projected that there'll be more than a dozen of these medications available in the coming years. So this is Arti Kavanaugh for RheumNow and coming to you from ACR Convergence.

Exciting meeting. Lot of data still to come. Tune in to RheumNow to hear about it.

I'm Anthony Chan reporting here at ACR twenty twenty four for RheumNow, and one of the key highlights of, today was the new preliminary ACR guidelines on the use of ultrasound in both rheumatoid arthritis and also psoriatic arthritis. I wanted to focus on the psoriatic arthritis area because it's one of the areas that I find clinically quite challenging to assess patients, especially when they don't always present with very straightforward clinical signs, and ultrasound will be a benefit. I'm very happy that I can be joined by the lead author from this morning's presentation, doctor Catherine Bakewell from Salt Lake City. Yes. And she presented the work today.

So welcome.

Thank you so much for having me. It's a pleasure to be here.

So the tell us about the the work that you've been doing with regards to developing these preliminary guidelines.

Absolutely. So this has been a labor of love as you heard this morning. It's been about a two year project. On the psoriatic arthritis side, I can tell you we had convened first with 13 different experts in addition to the court panel that developed a series of what we call Quick Go Questions. And The idea was to ask how can we better use musculoskeletal ultrasound and psoriatic arthritis both for diagnosis, contextualizing findings, determination of treatment escalation and remission.

And we then went through the literature. There's the real labor of love. It was over 3,800 articles that we came up with for ultrasound and psoriatic arthritis. And a series of 19 different literature reviewers whittled it down to just over 150 documents. And then we had a voting panel of 10 folks who were able to ring forward with a 70% consensus, 20 different people statements or guidance statements that you heard this morning, and thank you for coming and listening to that.

It was a very stringent methodology. Yes. Lots of review and lots of people getting involved in it. So just tell us what what does the main difference compared to the twenty twelve guidelines? So ten years down the line, what's different this time?

So for better, for worse, truly for better, but it made this a challenging project. There has absolutely been an explosion in the number of papers published, in the field of musculoskeletal ultrasound since the 2012 guidelines were published. A big difference just in the structure of what the output output will be is that in 2012 it was looking at the application of musculoskeletal ultrasound across the field of rheumatology, stating various areas where it was reasonable to use musculoskeletal ultrasound to evaluate for inflammatory disease and making statements like, for example, that SI joints would not be an appropriate location in absence of the availability of other imaging modalities. But this is truly focusing on rheumatoid arthritis, psoriatic arthritis, and narrowing it down to clinical application and day to day practice for the everyday rheumatologist. It's not meant to be just in clinical trials.

Mhmm.

So these guidelines are, you know, in many ways set the standards for this or what we should be looking for. But also, I was very, attracted to, you know, how do we use this practically in clinic. So if you could share with us some of your thoughts about how we're gonna translate this into clinical use. Absolutely.

So first and foremost, when we talk about diagnosis, we talked this morning about the concept of ultrasound and enhanced Casper classification criteria. So can we use musculoskeletal ultrasound to determine who we can put through the Casper not only escalation of therapy but determination of flares. What constitutes flares? And we talked about the concept that clinically normal joints can have ongoing synovitis and clinically swollen joints can have cruel residual fibrotic synovium. So you put the ultrasound transducer on and there may be no improper signal because somebody actually has burnt out or

has some disease on

their skin because it is

still swollen. And so one of the statements was MSUS can confirm your presence to flare. And that is also helpful in that patient provider discordant situation, right? So if a patient comes in and they may have significant symbitis on exam, but they're saying, Look, doctor, I really only want to use my doTERRA oils. I really don't want these.

I've read the package insert that this medicine concerns me. And it's so helpful to be able to put on the transducer, them the down person that lights up like fire, or you may have a large aversion and they say, Oh, this is really causing damage. This has a different risk benefit ratio than I was thinking. Or the opposite way is also true. So the patient with psoriatic arthritis and fibromyalgia who comes to me and says, Doctor, my psoriatic arthritis is flaring.

When you look at them and they look pretty good, they may not feel like they were taken as seriously if you don't have an extra look at the ultrasound. Show them the evidence of Doppler signal so that they really feel like you look underneath the skin and you're telling me, this isn't your psoriatic arthritis that is flaring. Let's talk about other ways we can help your pain.

I mean, that to me is one of the the key highlights from your presentation this morning of how you can take a guideline and then put into clinical practice. My shot of it is turning the sub what what for us is a very subjective assessment, doing objective assessment. Yes. You know, so the subjective becomes objective because of MSUS. That's And I think the big area that we maybe struggle is antisis, antisitis, because they're quite hard to sometimes assess.

Yes. So maybe a few words about maybe how we can take that kind of forward with this new guidelines with the use of MSUS, because you did show us some very nice work there.

Thank you. Emphasitis is such a key element or domain to

assess

St.

V. 24 brings

it up because all of the agents that we are shown now that say, Hey, look, this works for enthesitis. We're talking about clinical and VCL lunices where provider presses, the patient says, Ouch, that's counted as enthesitis. If they don't say, Ouch, it's counted as no enthesitis. So again, your patient with fibromyalgia all of a sudden has enthesitis, and your patient with subclinical inflammation who doesn't say ouch but is still inflamed doesn't even get counted towards the tally. So there really is a need for that objective assessment that ultrasound providers provides us.

We talked about the elementary lesions of empathicitis and how this can be used especially for diagnosis but also monitoring of treatment and remission.

I think that's really excellent. It kind of takes us to a different level. So just to wrap up, what would you say for our audience that key take home from your session today?

If you have not started scanning yet, now is the time to get into it. And I think we all are so busy in our day to day practices. I completely understand both the costs and the time limitation. But I do believe that this is a powerful tool. It just gives us more information to work with and base our clinical decisions off of.

And I really consider it my stethoscope in day to day practice. I get out there, buy one, it's worth it.

Alright there. Start scanning. Start going. Start looking at it. So you can refer to the video or the slide from today's presentation, and it gives you the outline of the preliminary guidelines.

And I think this is something that will certainly help us in our clinical practice. So, Catherine, thanks very much for your time. And this is Anthony Chan reporting here from Washington at ACR twenty twenty four.

Hi. It's doctor Arti Kavanagh coming to you from ACR Convergence twenty twenty four in Washington DC for RheumNow. Lot of interesting abstracts. Now I'm looking at things in psoriatic arthritis or related to, and let's start out with a couple things that are related to. There was a nice seminar on uveitis, and of course, uveitis is important across a number of rheumatic diseases, but I think it's especially relevant in psoriatic arthritis.

We see patients who have uveitis, and that can influence the treatment decisions. There's a seminar, Jim Rosenbaum gave a nice presentation, and there's a Doctor. Lerner gave a presentation on the pediatric aspect of uveitis, which was similar, although distinct. Anyway, there's a lot of data now in uveitis, and it's very exciting that it looks like we do have some options. TNF inhibitors are a natural, but there are other mechanisms that have had some interesting data that will help us manage patients for whom this is really an important comorbidity.

So, another, when we talk about psoriatic arthritis, and that was the seminar, let's look at some of the abstracts. We talk about psoriatic arthritis. We always talk about, also, about skin psoriasis. And I think an abstract that was very interesting was three zero three, was an oral TNF inhibitor. This is a Janssen drug, and I think the whole concept is very exciting.

The TNF inhibitors have been with us since the late '90s, and we've been using them in psoriatic arthritis since the early thousands for sure, and they really have established a central role in the treatment of psoriatic arthritis. Unlike our colleagues in skin psoriasis, where they now have better results with other mechanisms, such as IL-twenty three and IL-seventeen, in the joints for psoriatic arthritis, TNF inhibitors still have a central place and the most experience. We've always assumed they would be parenteral, but this is a fifty two week follow-up, long term extension study, dose finding study of an oral version of TNF inhibitor. Is it going to be just a pill with all the same attributes as the TNF inhibitor? Will there be differences?

We have to see. But it's very exciting. And then one more abstract, a couple of hot topics, and that's abstract two twenty three. Hot topics meaning the use of ultrasound, and also difficult to treat psoriatic arthritis. So this was from Ottawa, where they took patients and divided them using the EULAR assessment for difficult to treat RA, so not exactly the same, but I think it works well in psoriatic arthritis.

And they looked at the patients who had difficult to treat psoriatic arthritis compared to those whose psoriatic arthritis was not difficult to treat. Interestingly, they did not find many clinical differences in the readouts that we might think would be different, such as number of swollen joints. The ultrasound also was not different between the groups. So I think this really highlights the fact that there are other factors that go on as we're thinking about patient assessments, which are of course very important to our overall treatment approach to patients, and difficult to treat is complex. It's a complex construct which includes a number of different facets, not all of which are amenable to easy analysis like with the SEND.

So a lot of great presentations so far. We're just starting ACR convergence. This is Arti Kavanaugh from RheumNow.

Hello, everyone. I'm Catherine Bakewell. I'm reporting from ACR twenty twenty four. I'm standing next to my colleague and friend, Leahy Adder, and we're going to talk to you a little bit about updates from this ACR on ultrasound and psoriatic arthritis. There are two sessions that I wanna highlight today.

The first one was session, and I've got the number written down, 16 s o six. This is the ACR proposed, guidance statements for the use of musculoskeletal ultrasound in both rheumatoid and psoriatic arthritis. I would like to refer you actually to an interview with Antony Chen, that was done earlier today, but the bottom line is that the ACR combined with USONR is trying to put out everyday practical application statements for the clinician for the use of musculoskeletal ultrasound in both rheumatoid and psoriatic arthritis. How do we define these diseases diagnostically by ultrasound? How do we look at treatment response remission rates?

And how do we make this applicable in day to day clinical practice? I also have next to me Doctor. Lihi Ader who presented an update on Duet, a diagnostic ultrasound enthesitis tool, a combined international collaboration with GRAPA, the group research and assessment for psoriasis and psoriatic arthritis. I'm hoping she can tell us a little bit about what you taught us today.

Okay. DUET, is really aimed to develop a new diagnostic tool for antisitis, sonographic antisitis. We know that, it's very hard to accurate diagnose enthesitis in PSA, and we we hope that this new tool will help us, with early diagnosis of the disease. So this was really an international collaboration. We spent a lot of time training people, and, there was also a unique component of central scoring, which is not usually done in ultrasound studies.

We presented today the preliminary analysis, and, we what we found is that, first of all, many of the or some of the elementary lesions are not unique to PSA. I think this is, known to people that are doing ultrasound. Things like thickening, hypoecogenicity, and tesophytes can be found in older individuals, and so this is one thing to keep in mind. Secondly, lesions that seem to be more specific like power Doppler erosions were not very common in patients with early disease, but when they do appear, they seem to be very discriminative.

Yes.

The third important message is that the ability to discriminate antisitis by ultrasound between PSA and non PSA patients seem to be dependent on the Entezial site. So there are some sites like the patellar tendon insertions, the Achilles tendon, and the triceps tendon that seem to be more discriminative than areas like the plantar fascia or the supraspinatus insertion. So putting all of these together, these help helps us understand or think about the next steps, which are aimed to narrow down the number of sites that we need to scan, to weight some of the elementary lesions accordingly so those that are more discriminative will get higher weight. And ultimately, we to create total scoring system, total score that hopefully will help us make diagnosis early, think about prevention studies, and so on.

That's fantastic. I cannot wait for those results. I think this is fabulous work that you are doing and have done already, and I know we're eagerly awaiting the final results. Thank you so much for chatting with us today. Hi.

This is Artie Kavanaugh coming to you from the American College of Rheumatology Convergence '2 thousand twenty four in Washington, D. C. For RheumNow. So lots of subjects being covered about lots of diseases, big interest in psoriatic arthritis, and a very recent interest in psoriatic arthritis has the impact of sex on the disease characteristics and, of course, the response to therapy. There have been a couple of abstracts on that, seventeen oh nine, fourteen seventy one, and there was also a seminar where Leahy Ader, who's the senior author on those other abstracts, was talking about the response to therapy, and Laura Coates was talking about just differences in disease characteristics in psoriatic arthritis patients based on sex.

It's an interesting topic. Among the rheumatic diseases, Celiac arthritis is one that's about equal in men and women, about fiftyfifty, unlike rheumatoid arthritis where it's eighty women for 20 men, or ankylosing spondylitis where it's reversed. So I guess for a while we didn't really consider the impact of sex as we do for something like systemic lupus, but it does have a lot of relevance, and it's been a topic that hasn't had a lot of attention paid to it, but it's certainly changing now. If you take baseline characteristics of patients with psoriatic arthritis, for example, in clinical research studies, there are differences that you see in a lot of studies. Women tend to have more pain and assess their global activity and function worse.

Men tend to have a little bit more inflammation measured by the CRP, and more skin disease relatively. Over the course of treatment, in general, across quite a number of therapies, it seems like the response or the effect size for women with PSA may be less than that of men. The intriguing thing is we really don't know why. Some people have suggested that maybe it's a pain, their perception of pain, and that certainly can be different between the sexes. But there are also distinct immunologic differences, and the subtypes of different immune active cells like macrophages, we don't know how that relates to the clinical differences nor to the response to therapy.

Of course, that too is a very complex topic as the hormonal milieu for men and women absolutely changes over time. How does that change impact the clinical manifestation? So a lot that we don't know, but I think we all recognize now that there can be important differences. So we're at least paying more attention to clinical trials to know that the data need to be assessed according to the sex of the patient, among the other important baseline characteristics. So kind of a stay tuned.

I think this is an area that's a hot topic. I think it's one, hopefully, we'll have really more concrete answers for in the future, which will help us take care of our patients with psoriatic arthritis. From the American College of Rheumatology Convergence, Washington DC, this is Arti Kavanaugh for RoomNow.

Hi, this is Catherine Bakewell reporting to you for RoomNow. I'm Washington DC for ACR twenty twenty four and I wanted to tell you about the best thing that I saw today, which was related to sex differences in psoriatic arthritis. We started off the day with session 17S08. It was a combined session by Laura Coates and Leahy Adder. And we learned that females have a significantly different baseline characteristic profile as well as response to therapy.

So females by and large are going to report more pain and disability. They're going to have higher overall composite disease activity scores. They're going to have lower drug persistence, aka discontinued drug, more often and more adverse events related to medication, which again you would assume is a correlate to that as well. Whereas males are going to have higher CRP levels, higher levels of dactylitis, PASI scores, AKA worse skin psoriasis, and more radiographic progression. But the good news for them is that they tend to have better treatment response.

Interestingly, they also highlighted some data around ultrasound that of course I as a lover of ultrasound found particularly fascinating, was that men tend to have higher ultrasound and the size scores both by grayscale and color power Doppler whereas women tended to have higher clinical and the site scores. And to me this underscores not only the importance of objective measurement, aka with ultrasound showing true but we need to better understand why is it that our females in general have more pain reporting, more pain in general. Those are probably a gender related difference in our gender expectations around the stoic man not reporting his pain, whereas it would be more okay for the woman to talk about her discomfort. But also we know that hormones significantly impact immune function and pain processing itself. So Doctor.

Ader showed us a slide showing us that microglia in the level of the spinal cord in men regulate pain signaling whereas in women it tends to be more T cell regulated. Doctor. Ader also showed us a meta analysis of 54 different randomized controlled clinical trials looking at ACR responses in psoriatic arthritis and specifically looking at ACR 20 responses. Only nine of the 54 RCTs reported sex disaggregated data, AKA showing us how men responded differently to women. But when analyzed, it did appear that there was a tendency for the men to respond better to biologic therapy.

All of them examined TNF inhibitors, IL-twelve twenty three, IL-twenty three inhibitors, IL-17s, whereas there was less of a gender discrepancy for the targeted small molecules of JAKs and TYK2s. One mechanism for this, she also showed us a study that demonstrated that women have higher immunogenicity to at least infliximab, so maybe there is an issue there. But regardless, we need more data. Nine out of fifty four is not good. She shows us how they don't separate women based upon whether you're 20, whether you're 80, it's all lumped into one pile and again a minority of these trials differentiated by men versus women at all.

Last abstract I want to highlight for you this is seventeen oh nine entitled Sex Differences in Serum Proteomic Profiles of Males and Females with Psoriatic Arthritis. This was presented by Stephen Dang and it did demonstrate that men had an over 20 fold increased level of protein deregulation relative females. That unfortunately, they did not measure estrogen and testosterone levels, but they did break down the women into premenopausal and postmenopausal status. So there is some hope that we're gathering more hormone related data, but we do need to be studying our females more closely, both for hormone levels throughout the menstrual cycle, but also pregnancy, nursing related, and of course pre or post menopausal status. We also need to be gathering data around gender and the impact that that can have on response to therapy in psoriatic arthritis.

So a call out to those in industry to please join us in this fight. I will mention doctor Adder one last time that she is running the SAGE trial examining sex and gender related differences in PSA response. And that's all I have for you today. Thank you.

I'm Anthony Chan reporting here for RheumNow in ACR twenty twenty four in Washington DC. I've been going around looking at posters this morning, and I came across an interesting poster that I want to share with you. I think it's interesting because it talks about people having psoriatic arthritis before psoriasis. This is poster 200328. Now usually we would think about patients having psoriatic arthritis after the onset of psoriasis.

I work on a seventeen fifteen fifteen rule and that rule is seventy percent of patients will have psoriasis and then psoriatic arthritis later. Fifteen percent will have it at the same time simultaneously and another fifteen percent will have the psoriatic arthritis first before the psoriasis. And in this study from Toronto they worked out that it was a bit lower this time and the number of patients were eight point six percent, who had developed PSA before psoriasis and I'm going to share with you five key highlights from this, poster. Number one disease characteristics, what were they like? These patients who had PSA before PSO had a higher disability index, we call it this time broker score and they had more severe structural damage compared to those, who would develop psoriasis, or psoriatic arthritis later.

Secondly, those who had PSA first before PSO, they were more HLAB twenty seven positive, whereas in the other groups, they had the HLAC6 positivity which is traditionally what we see in patients who have PSO first. Thirdly, the disease activity, they looked at both groups those who had developed PSA first and those who developed PSO first and found that the mean swollen joint count was equal No significant difference between the the two groups. Number four, they had they looked at radiographic progression and those who had developed PSA first had a higher risk of faster radiographic progression. Forty three percent of this group had more radiographic progression compared to those who developed PSO first and this was related to older age and also the modified Steinebroker score. And finally the treatment impact.

The use of advanced therapies was protective in this group, who are at risk of radiographic progression which is the PSA first group. So while only a small minority of our patients that we see in our clinic may develop, the PSA first before the PSO, It's important to, be looking out for these patients because they may not demonstrate the skin manifestations in this small cohort compared to the traditional group which have the PSO first. So I'm Anthony Chan reporting here for RheumNow in Washington DC. Thank you.

Hello, everyone, and I'm glad to be able to report from the February in Washington DC. Interesting are posters in which my site had a part in the construction of data. One of them is Apremilaz reduces axial inflammation in patients with psoriatic arthritis using a CANDEM MRI scoring. This was a phase four analysis from the MOSAIC trial using a Premilas as the primary agent in patients specifically with axial PSA within the cohort of the patients with overall psoriatic arthritis. The medium age of these patients was 47 years old with a duration of disease of approximately one point nine years.

These patients were all on background therapy and the important thing here to report is that psoriatic arthritis or psoriatic spondylitis is an active aspect of the life of patients with psoriasis. So the purpose of this study was to explore using whole body MRI the aspects of inflammation using this novel CANDEM methodology. So the patients had to have psoriatic arthritis, obviously peripheral arthritis, had to fulfill the CASPER criteria and whole body MRI with contrast obtained at baseline twenty four and forty eight weeks. And the purpose was again to try to establish a cause relationship or perhaps an association or an observation of the impact of APREMILAS in axial disease in patients with psoriatic arthritis. So of a total of one hundred and twenty two patients in the cohort, forty patients met the criteria for axial spondylitis using the BasDie questionnaire.

This actual inflammation permitted patients to be involved and evaluated through the methodology the first time perhaps reported in a study of this nature using whole body MRI with contrast to assess characteristics associated with axial pathology in these patients with psoriatic arthropathy. So the results showed that CANDEM analysis allowed us to demonstrate that there was evidence of significant differences between the patients who were on treatment at different time points showing superiority in all the different aspects of the readout using the CANDEN methodology. However, when the patients were subject to Spark criteria, they do not meet that endpoint. What is the message that we get from this abstract is that psoriatic spondylitis is an important part of the life of patients with psoriatic arthritis. We know that the APREMILAS studies were not used or they don't use radiographic methods in the registration trials, but the spirit of having this trial was to demonstrate further that APREMILAS still apparently has an impact on controlling certain aspects of inflammation as we see with this very clear methodology using the CANDEM which enables us to see not only the vertebral aspects of the inflammation but also the posterior vertebral aspect of inflammation.

Summary would be that it's important to know and important to learn what using this method teach us about the axial impact of aprimilaz in these patients. Thank you.

Hi, this is Eric Dine from ACR Convergence Day three. Here's what I'm looking forward to today on our last full day in Washington, D. C. I'm looking at the IL-seventeen data. There's a lot of information about some of the new medicines like bimekizumab and also some data about some of the older medicines like secukinumab.

We know that one of the benefits of IL-seventeen is its efficacy on enthesitis. One of the abstracts being presented today is 2,586 looking at the tissue effects on an endothelial tissue. The EBO study is looking at minimally invasive ultrasound guided biopsies of enthesitis, particularly looking at the lateral epicondyles of patients with active enthesitis. What they do is they established a baseline ultrasound guided biopsy and then they repeated it after at least three months of being on secukinumab therapy. They had 10 patients enrolled in the study.

They had nine of them that they got the secondary biopsy to complete a before and after. What they found was they found that there was definite improvement in that tissue inflammation in the enthesis after initiation of the IL-seventeen inhibitor. They found that neutrophils, CD4 plus T cells, and IL-seven was decreased with a particular benefit of the IL-17A fractions of cell types being decreased in patients on an IL-17A inhibitor. So this is very useful information. They showed major effects on the transcriptional states of the resident endothelial cells.

So it's good to see in practice, in actual data in the tissue, to see that when we give an IL-seventeen inhibitor that we see that inflammatory response decreasing in the target in those entheses. Definitely great data to show that our agents for IL-seventeen are helpful for addressing our active enthesitis. Lots of great coverage here at RheumNow. Stay tuned for more information.