Difficult To Treat Psoriatic Arthritis Save
Dr. Peter Nash reports at Eular 2024 in Vienna, Austria.
Transcription
Hi, everybody. Peter Nash reporting for RheumNow at EULA Vienna twenty twenty four. One of the sessions that was quite interesting in the AxSpA PSA space is initiative that's being driven both by EULA and by GRAPA to define difficult to treat PSA. It's been popular that difficult to treat RA, difficult to treat AS, and now they're trying to define difficult to treat PSA. So what are the three views about this particular subject?
The definition of difficult to treat PSA will depend on an SLR, it will depend on patient room surveys, but the bottom line is going to be that to be called difficult to treat, you have to fail one conventional synthetic DMARD, two biologics of different mechanism of action and have ongoing evidence of inflammation. Not laboratory markers, but imaging markers, MRI or ultrasound of active inflammation. So that's defining difficult to treat. Now they're separating that from the second issue, which they're calling complex to manage PSA. Now they're people who have no evidence of inflammation have failed a number of drugs often cycle endlessly through expensive biologics but their pain is considered non musculoskeletal pain, chronic widespread pain, central sensitization pain.
And these people are just asymptomatic, but rather than cycling through biologics, you should think about non drug initiatives as well as things like pregabalin, tricyclics and treating them along neuropathic and nociplastic lines. Just as valid, but a different way of treating these particular patients and non drug methods may be very helpful. Even things like cannabis might be helpful, but that needs to be proven. Now the third aspect of this whole discussion is what are the implications of diagnosing difficult to treat PSA in the first instance? Well, it's got to have therapeutic implications.
We have to start thinking of ways of defining them early and doing something more aggressive early to try and break that vicious cycle. It might be combinations from day one. It might be safe combinations like TNF plus IL-seventeen inhibition or TNF plus IL-twenty three inhibition, a study currently undergoing worldwide use right now. So how you get two biologics for your patient is very difficult. In our country for these very difficult patients, we have the RheumNow prescribe one biologic and our Durham College colleague prescribe the other.
It has to be a safe combination. I don't think JAK plus TNF will be safe because of, adverse effects, but some of the newer agents like 17s and twenty three, there'll be no safety signal if you use them in combination, but that has to be proven. So this is an ongoing field of interest, to treat, complex to manage, then the implication of what you're going to do about it. Thanks for your attention.
The definition of difficult to treat PSA will depend on an SLR, it will depend on patient room surveys, but the bottom line is going to be that to be called difficult to treat, you have to fail one conventional synthetic DMARD, two biologics of different mechanism of action and have ongoing evidence of inflammation. Not laboratory markers, but imaging markers, MRI or ultrasound of active inflammation. So that's defining difficult to treat. Now they're separating that from the second issue, which they're calling complex to manage PSA. Now they're people who have no evidence of inflammation have failed a number of drugs often cycle endlessly through expensive biologics but their pain is considered non musculoskeletal pain, chronic widespread pain, central sensitization pain.
And these people are just asymptomatic, but rather than cycling through biologics, you should think about non drug initiatives as well as things like pregabalin, tricyclics and treating them along neuropathic and nociplastic lines. Just as valid, but a different way of treating these particular patients and non drug methods may be very helpful. Even things like cannabis might be helpful, but that needs to be proven. Now the third aspect of this whole discussion is what are the implications of diagnosing difficult to treat PSA in the first instance? Well, it's got to have therapeutic implications.
We have to start thinking of ways of defining them early and doing something more aggressive early to try and break that vicious cycle. It might be combinations from day one. It might be safe combinations like TNF plus IL-seventeen inhibition or TNF plus IL-twenty three inhibition, a study currently undergoing worldwide use right now. So how you get two biologics for your patient is very difficult. In our country for these very difficult patients, we have the RheumNow prescribe one biologic and our Durham College colleague prescribe the other.
It has to be a safe combination. I don't think JAK plus TNF will be safe because of, adverse effects, but some of the newer agents like 17s and twenty three, there'll be no safety signal if you use them in combination, but that has to be proven. So this is an ongoing field of interest, to treat, complex to manage, then the implication of what you're going to do about it. Thanks for your attention.
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