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doi: 10.46497/ArchRheumatol.2021.7874
Arch Rheumatol 2021;36(1):1-9
ORIGINAL ARTICLE
©2021 Turkish League Agains t Rheumatism. All right s reserved. Open Access
Clinical characteristics, disease activity, functional status, and quality
of life results of patients with psoriatic arthritis using biological and
conventional synthetic disease-modifying antirheumatic drugs
Yaşar Keskin1, Kemal Nas2, Erkan Kılıç3, Betul Sargın4, Sevtap Acer Kasman5, Hakan Alkan6,
Nilay Şahin7, Gizem Cengiz8,9, Nihan Cuzdan10, İlknur Albayrak Gezer11, Dilek Keskin12,
Cevriye Mülkoğlu13, Hatice Resorlu14, Şebnem Ataman15, Ajda Bal16, Mehmet Tuncay Duruoz5,
Okan Küçükakkas1, Ozan Volkan Yurdakul1, Meltem Alkan Melikoğlu17, Yıldıray Aydın2,
F. Figen Ayhan13,18, Hatice Bodur19, Mustafa Çalış8, Erhan Çapkın20, Gül Devrimsel21, Kevser Gök22,
Sami Hizmetli23, Ayhan Kamanlı2, Hilal Ecesoy24, Öznur Kutluk25, Nesrin Şen26, Ömer Faruk Şendur27,
İbr a him Teke o ğ lu2, Sena Tolu28, Murat Toprak29, Tiraje Tuncer25
1Department of Physical Medicine and Rehabilitation, Bezmiâlem Foundation University, Istanbul, Turkey
2Department of Physical Medicine and Rehabilitation, Division of Rheumatology and Immunology, Sakarya University School of Medicine, Sakarya, Turkey
3Department of Physical Medicine and Rehabilitation, Rheumatology Clinic, Kanuni Training and Research Hospital, Trabzon, Turkey
4Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Adnan Menderes University School of Medicine, Aydın, Turkey
5Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Marmara University School of Medicine, Istanbul, Turkey
6Department of Physical Medicine and Rehabilitation, Pamukkale University School of Medicine, Denizli, Turkey
7Department of Physical Medicine and Rehabilitation, Balıkesir University School of Medicine, Balıkesir, Turkey
8Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Erciyes University School of Medicine, Kayseri, Turkey
9Department of Physical Medicine and Rehabilitation, Rheumatology Clinic, Van Training and Research Hospital, Van, Turkey
10Department of Physical Medicine and Rehabilitation, Rheumatology Clinic, Şanlıurfa Training and Research Hospital, Şanlıurfa, Turkey
11Department of Physical Medicine and Rehabilitation, Selçuk University School of Medicine, Konya, Turkey
12Department of Physical Medicine and Rehabilitation, Kırıkkale University School of Medicine, Kırıkkale, Turkey
13Department of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Ankara , Turkey
14Department of Physical Medicine and Rehabilitation, Çanakkale Onsekiz Mart University School of Medicine, Çanakkale, Turkey
15Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Ankara University School of Medicine, Ankara, Turkey
16Department of Physical Medicine and Rehabilitation, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
17Depar tment of Physical Medicine and Rehabilitation, Division of Rheumatology, Atatürk University School of Medicine, Erzurum, Turkey
18Department of Physical Medicine and Rehabilitation, Uşak University, High School of Health Sciences, Uşak, Turkey
19Department of Physical Medicine and Rehabilitation, Yıldırım Beyazıtuniversity School of Medicine, Ankara, Turkey
20Department of Physical Medicine and Rehabilitation, Karadeniz Technical University School of Medicine, Trabzon, Turkey
21Department of Physical Medicine and Rehabilitation, Recep Tayyip Erdoğan University School of Medicine, Rize, Turkey
22Department of Physical Medicine and Rehabilitation, Ankara Numune Training and Research Hospital, Ankara, Turkey
23Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Cumhuriyet University School of Medicine, Sivas, Turkey
24Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
25Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Akdeniz University School of Medicine, Antalya, Turkey
26Department of Physical Medicine and Rehabilitation, Rheumatology Clinic, Kartal Dr. Lütfi Kırdar Training and Research Hospital, Istanbul , Turkey
27Department of Physical Medicine and Rehabilitation, Adnan Menderes University School of Medicine, Aydın, Turkey
28Department of Physical Medicine and Rehabilitation, Medipol University School of Medicine, Istanbul, Turkey
29Department of Physical Medicine and Rehabilitation, Yüzüncü Yıl University School of Medicine, Van, Turkey
Received: November 07, 2019 Accepted: January 24, 2020 Published online: July 01, 2020
Correspondence: Yaşar Keskin, MD. Bezmiâlem Vakıf Üniversitesi Tıp Fakültesi Hastanesi, Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, 34093 Fatih, İstanbul, Türkiye.
Tel: +90 212 - 523 22 88 e-mail: ykeskin42@hotmail.com
Citation:
Keskin Y, Nas K, Kılıç E, Sargın B, Acer Kasman S, Alkan H, et al. Clinical characteristics, disease activity, functional status, and quality of life results of patients
with psoriatic arthritis using biological and conventional synthetic disease -modifying antirheumatic drugs. Arch Rheumatol 2021;36(1):1-9.
This is an op en access article un der the terms of the Crea tive Commons Attrib ution-NonCo mmercial License. w hich permits use. d istribution and re production in any m edium. provide d
the origin al work is properly c ited and is not used fo r commercial purpo ses (http://creativeco mmons.org/lic enses/by-nc/4. 0/).
Arch Rheumatol
2
Psoriatic arthritis (PsA) is an inflammatory
disease that can affect the peripheral joints, axial
skeleton, skin, and nails. The disease is part of the
spondyloarthritis group and related to psoriasis.1
Psoriatic arthritis is a heterogeneous disease
that can vary from a mild disease state to an
erosive and deformative state.2 If left untreated,
it can cause progressive joint damage, disability,
disruption of functional status, decreased quality of
life (QoL), and significantly increased mortality.3-5
Disability and increased mortality in PsA can be
associated with both inflammatory skin lesions
and joint damage.
Conditions such as disability, decreased
physical activity, long-term comorbidities, and
increased anxiety and depression during PsA
further increase the burden of the disease.6,7 Early
diagnosis and adequate treatment methods may
help in avoiding such complications.8
According to the European League Against
Rheumatism (EULAR) and Group for Research
and Assessment of Psoriasis and Psoriatic
Arthritis (GRAPPA) treatment guidelines, there
are multiple treatment options available for PsA.
The treatment is designed based on disease
severity and disease activity. Treatment options
include pharmacological and non-pharmacological
strategies.9 Non-pharmacological strategies
include patient training, exercise, and weight
loss along with physical, occupational, and
psychological therapies. In mild-to-medium disease
activity, the disease is treated with conventional
synthetic disease-modifying antirheumatic drugs
(csDMARDs) and non-steroidal anti-inflammatory
drugs (NSAIDs). If this treatment is not effective or
if intolerance and side effects emerge, biological
DMARDs (bDMARDs) can be added to the
treatment regime.10 The objective is to control the
symptoms and inflammation, prevent progressive
structural damage, and increase the QoL of
the patients as much as possible by aiming for
clinical remission through appropriate treatment
options.11 In this study, we aimed to compare
the clinical characteristics, disease activity, and
QoL of patients with PsA who use biological and
conventional synthetic DMARDs in a nationwide
cohort throughout Turkey.
PATIENTS AND METHODS
This cross-sectional study was conducted
between February and December in 2018. The
study included the demographic characteristics
and clinical and laboratory data of 961 PsA
patients (346 males, 615 females; mean age:
46.9±12.2 years; range, 18 to 81 years) who
were treated as part of their routine examinations.
The clinical data obtained during the routine clinic
visits of the patients were added to the electronic
forms by using a national network that also serves
as a scientific research cooperation platform
(https://www.trasd-network.org). Patients with
PsA from 25 different centers (University as
well as Training and Research Hospitals) in
Turkey who met the classification criteria for
PsA, were undergoing csDMARD and bDMARD
monotherapy or a combination treatment, aged
ABSTRACT
Objectives: This study aims to compare the clinical characteristics, disease activity, and quality of life (QoL) of patients with psoriatic arthritis (PsA)
who use biological and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in a nationwide cohort throughout Turkey.
Patients and methods: A total of 961 patients (346 males, 615 females; mean age: 46.9±12.2 years; range, 18 to 81 years) with PsA according to the
classific ation criteria for PsA were inclu ded in the study. The patients’ demographi c and clinical characteristics, physical examination result s, Disease
Activity Score 28, Disease Activity Index for Psoriatic Arthritis and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Psoriasis Area and
Severity Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, Hospital Anxiety and Depression Scale,
Health Assessment Questionnaire, Psoriatic Arthritis Quality of Life (PsAQoL), and Short Form-36 scores were all recorded.
Results: Of the patients, 23% underwent biological DMARD (bDMARD) monotherapy, 42% underwent conventional synthetic DMARD (csDMARD)
monotherapy, 10% underwent a csDMARD combination therapy, and 10% underwent a combination bDMARD and csDMARD treatment. The Visual
Analog Scale (VAS pain), patient global assessment, physician global assessment, and BASDAI scores were found to be lower among patients using
combination tr eatment of csDMARD and bDM ARD, while the swollen joint cou nt was found to be lower among pat ients using bDMARD. The PsAQo L
score was found to be the lowest among patients not using any medication and the highest among those using bDMARD.
Conclusion: In our study, patients with PsA were successfully treated with both csDMARD and bDMARD monotherapy. When the biological
treatments used for PsA were compared with csDMARD, it was found that biological treatments had a positive effect on both disease activity and
the QoL. Combinations of csDMARDs and bDMARDs were preferred in cases in which the disease activity was still high or increased. Because of the
highest efficacy of the combined treatment, we highly suggest increasing the number of patients on combined treatment.
Keywords: Disease-modifying antirheumatic drug, functional status, psoriatic arthritis, quality of life.
3
Patients with psoriatic arthritis using biological and conventional synthetic DMARDs
above 18 years, and had no other rheumatic
disease(s) were included in the study. Patients who
were diagnosed with psoriasis by dermatologists
but who did not have arthritis, female patients who
were pregnant or breastfeeding and patients with
malignancies were excluded. The study protocol
was approved by the Sakarya University Faculty
of Medicine Ethics Committee (Approval date/no:
25.01.2018/42). A written informed consent
was obtained from each patient. The study was
conducted in accordance with the principles of
the Declaration of Helsinki.
Patients were divided into four groups
according to the given treatment as those who
were not using any medication, those who
received csDMARD monotherapy, those who
received bDMARD monotherapy, and those
under combination bDMARD and csDMARD
therapy.
Patients’ demographic characteristics (sex and
age), body mass index (BMI), age at the onset of
psoriasis (years), age at the onset of PsA (years),
duration of psoriasis (years), duration of PsA
(years), delay in PsA diagnosis (years), patient
global assessment (PtGA), and physician global
assessment (PhGA) were recorded.
Tender joint count and swollen joint count
(SJC) of the patients were checked during the
examination. The pain of the patients was evaluated
using the Visual Analog Scale (VAS-pain).
Disease activity of the patients was evaluated
using the Disease Activity Score 28 (DAS28),
Disease Activity Index for Psoriatic Arthritis
(DAPSA), and the Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI).1 2,13 Psoriasis
severity was evaluated using the Psoriasis Area
and Severity Index,14 and the functional status was
evaluated using the Bath Ankylosing Spondylitis
Functional Index,15 and the Bath Ankylosing
Spondylitis Metrology Index.16 The risk of anxiety
and depression was evaluated using the Hospital
Anxiety and Depression Scale, and the QoL
was evaluated using the Health Assessment
Questionnaire (HAQ),17 Psoriatic Arthritis Quality
of Life (PsAQoL),18 and the short form (SF)-36.19
Statistical analysis
Statistical analyses were performed using the
IBM SPSS for Windows version 22.0 software
(IBM Corp., Armonk, NY, USA). Whether the
continuous numerical variables were normally
distributed was evaluated using the Shapiro-Wilk
test. Results of the numerical variables were
presented as mean ± standard deviation (SD).
Because the comparisons between the groups did
not show a normal distribution, non-parametric
tests were used. To compare the data for
determining the level of significance between
the groups, Kruskal-Wallis test was used for
continuous variables, while the chi-square test or
Fisher’s exact test was used for the categorical
variables. In all statistical analyses, the level of
significance was considered as p<0.05.
RESULTS
The study included patients with complete
treatment data constituted using the
TRASD-network. Of these patients, 36% were
males and 547 (57%) were active smokers. Mean
BMI was 28.4 (17.7-53.3) kg/m2, and average
duration of symptoms was seven years (range,
0 to 59 years). Hip pain, peripheral arthritis,
spondylitis, and inflammatory back pain were
identified in 211 (22%), 430 (45%), 351 (37%),
and 430 (45%) of the patients, respectively.
There was no difference between the groups
with regards to active smoking rates. The
incidence of chronic back pain (50%) and morning
stiffness in spine (49%) was high among the
patients not using any medication, while that of
spondylitis (47%), inflammatory back pain (57%),
and enthesopathy (48%) was high among patients
using bDMARD. The incidence of peripheral
arthritis (73%) was the highest among patients
using csDMARD. While the time span for delay
in diagnosis of PsA was similar between the
groups, the duration of symptoms (10 years;
range, 1 to 49 years) and the duration since PsA
diagnosis (7 years; range, 1 to 39 years) were
determined to be the highest in the group using
a combination of csDMARD and bDMARD and
the lowest in the group not using any medication
(5 years; range, 0 to 42 years and 2 years; range,
0 to 41 years, respectively) (Table 1).
Of the patients, 221 (23%) underwent bDMARD
monotherapy (adalimumab: 73, etanercept: 49,
infliximab: 35, golimumab: 22, certolizumab
pegol: 26, ustekinumab: 10, and secukinumab: 6);
407 (42%) underwent csDMARD monotherapy
Arch Rheumatol
4
Table 1. Demographic and clinical disease activity characteristics in patients treated with disease-modifying antirheumatic drug
Tot a l (n =961) No DMARD (n=139) csDMARD (n=501) bDMARD (n=221) Combination
DMARD (n=100)
p
Age (year)* 47 (18 -81) 48 (20 -72) 47 (18-81) 46 (18-72) 46 (21-77 ) 0.557
Body mass index (kg/m2)* 28. 4 (17.7- 5 3 . 3) 28.5 (19.3-44.8) 28 .4 ( 17.7- 42.9 ) 2 8.7 (19.4-4 3) 27.7 (18.4-53.3) 0.609
Active smoker, n (%) 547 (57 ) 38 (28) 116 (23) 66 (30) 30 (30) 0.218
Sex
Male, n (%) 346 (36) 45 (33) 148 (29 ) 108 (49) 45 (45) <0.001
Visual Analog Scale-pain (0-10)* 5 ( 0 -10 ) 5 ( 0 -10 ) 5 ( 0 -10 ) 4 ( 0 -10 ) 4 ( 0 -10 ) 0.034
Patient global assessment (0-10)* 4 (0-10) 5 (0-10) 5 (0-10) 4 (0-10) 4 (0-10) 0.017
Physician global assessment (0-10)* 4 ( 0 -10 ) 4 ( 0 -10 ) 4 ( 0 -10 ) 4 (0-8) 3 (0-9) 0.029
Spondylitis, n (%) 351 (37) 42 (31) 163 (32) 103 (47) 43 (43) 0.001
Inflammatory back pain, n (%) 430 (45) 56 (41) 199 (40 ) 125 (57) 50 (50) <0.001
Gluteal pain, n (%) 234 (24) 34 (25) 102 (2 0) 76 (34) 22 (22) <0.001
Hip pain, n (%) 211 (22) 37 (27) 94 (19) 64 (29) 16 (16) <0.001
Arthritis, n (%) 430 (45) 80 (58) 365 (73) 123 (56) 70 (70) <0.001
Enthesitis, n (%) 638 (66) 44 (32) 191 (38 ) 105 (48) 51 (51) 0.0 02
Tender joint count* 2 (0-56) 2 (0-56) 2 (0-50) 2 (0 -51 ) 2 (0-45) 0.0 62
Swollen joint count* 0 (0-28) 0 (0-24) 0 ( 0-23) 0 (0-24) 0 (0 -28) 0.0 01
Disease Activity Score 28* 3. 2 ( 0 -7. 5 ) 3.4 (0 -6.4) 3.4 ( 0 -7.5 ) 2 . 9 (0 -7.4 ) 2.9 (0- 6.7 ) <0.001
Disease Activity Index for Psoriatic Arthritis* 17.2 (0-111.9) 17.8 (3.8-111.9) 18.8 ( 0-10 4) 14. 6 ( 0 -76 .5 ) 13.3 (1.6-84.5) 0.002
BASDAI score* 3. 4 ( 0 -10 ) 4 .3 ( 0 -10 ) 3 .5 ( 0 -10 ) 3 (0-10) 2.9 ( 0-9.6) 0.007
BASMI score* 1 (0-9) 1 (0-8) 1 (0-9) 2 (0-8) 2 ( 0-7) 0.483
BASFI score* 1.5 (0 -10 ) 1.2 ( 0 -10 ) 1.5 ( 0-10) 1.4 ( 0 -10 ) 1.9 (0-9) 0.506
Psoriasis Area Severity Index total score* 1.5 ( 0-51.3) 2 (0-26 .7) 1.6 (0-51.3 ) 1.2 (0-24.6) 1.3 (0-46.8) 0.055
FACI T s core* 18 ( 0 -51) 18 (2-5 0) 18 (0- 48 ) 19 (0 - 51) 17.5 (0 - 4 5 ) 0. 811
Symptom durations (year)* 7 (0-59) 5 (0- 42) 6 (0.1-59) 10 (0.3- 48) 10 (1- 49) < 0.0 01
Symptom durations (year)* 5 (0-4 4) 2 (0- 41) 4 (0-37) 6 (0-44) 7 (1-39) <0.001
Diagnostic delay (year)* 1 (0-32) 1 (0-32) 1 (0 -27) 1 (0-29) 1 (0-1 6) 0.228
Psoriatic Arthritis Quality of Life score* 5 (0-20) 4 (0 -20) 5 (0-20 ) 5 (0 -20) 4 (0 -20) 0.240
HAQ sco re* 0.3 (0 -2.5) 0.3 (0-2) 0.3 (0-2.5) 0.3 (0-2.4) 0.2 (0-2.5) 0.800
HAQ -S score* 0.5 (0-2.8) 0.5 (0-2.8) 0.5 (0-2.7 ) 0.3 (0-2.8) 0.5 (0-2 .7) 0.465
Physical functioning* 70 (0 -100 ) 70 ( 0 -10 0 ) 70 ( 0-10 0) 70 ( 5 -10 0) 72 .5 ( 0 -10 0) 0.328
Role-physical* 5 0 (0-1 00) 5 0 (0 -10 0 ) 50 ( 0 -10 0) 5 0 ( 0 -10 0 ) 7 5 ( 0 -10 0 ) 0.371
5
Patients with psoriatic arthritis using biological and conventional synthetic DMARDs
(methotrexate [MTX]: 295; Sulfasalazine [SSZ]:
62, and others: 50), and 94 (10%) underwent
csDMARD combination treatment. In addition,
100 (10%) patients with PsA who underwent
bDMARD treatment were administered a
combination therapy with any csDMARD as well.
It was found that 137 (14%) of the patients did not
undergo any DMARD treatment (Table 2).
Notably, the VAS-pain, PtGA, PhGA, SJC,
and BASDAI scores were the highest in the group
not using any medication (5, range, 0 to 10; 5,
range, 0 to 10; 4, range, 0 to 10; 0, range, 0 to
24; and 4.3, range, 0 to 10, respectively), while
the VAS-pain, PtGA, PhGA, and BASDAI scores
were the lowest in the combination csDMARD
and bDMARD group (4, range, 0 to 10; 4, range,
0 to 10; 3, range, 0 to 9; and 2.9, range, 0 to
9.6, respectively). The SJC was the lowest in
the bDMARD group (3, range, 0 to 10). DAS28
score was the highest in the group not using any
medication (3.2, range, 0 to 7.5) and lowest in
both groups using bDMARD (2.9, range, 0 to 7.4)
and combination of csDMARD and bDMARD
(2.9, range, 0 to 6.7). The DAPSA score was the
highest in the group not using any medication
(17.2, range, 0 to 111.9) and the lowest in
Table 1. Continued
Tot a l (n =961) No DMARD (n=139) csDMARD (n=501) bDMARD (n=221) Combination
DMARD (n=100)
p
Bodily pain* 67. 5 ( 0 -10 0 ) 5 7.5 ( 0 -10 0 ) 62. 5 (0-100) 67. 5 (0 -10 0 ) 67.5 (12.5-100) 0.006
General health* 4 5 ( 0 -10 0 ) 50 (0-90) 45 ( 0-10 0) 45 (0-100) 45 (5-95) 0.212
Vitality* 4 0 (0 -75) 40 ( 0 -70 ) 40 (0 -75) 40 ( 0-75 ) 40 (0 -75) 0.947
Social functioning* 75 ( 0 -10 0) 75 ( 12 . 5-10 0) 75 ( 0-10 0) 6 2.5 (0-100) 75 ( 2 5 -10 0) 0.565
Role-emotional* 6 6.7 ( 0 -10 0) 66.7 ( 0-10 0) 66 .7 (0-100) 66 .7 (0-100) 100 (0-100) 0.234
Mental health* 60 ( 0-10 0) 56 (8-100) 6 0 (0 -100 ) 60 (0 -100 ) 68 (8-92) 0.134
SF-36-Physical component summary score* 58.8 (3.8-100) 57.5 (10.5-97.5) 56.8 (3.8-100) 59.3 (6.3-100) 67.4 (13-9 8.8) 0.479
SF-36-Mental component summar y score* 60 (5-93.8) 59.3 (8.3-90.5) 60.1 (5-93. 8) 55.8 (7.3-91.5) 63.8 (17.3-91.8) 0.380
DMARD: Disease-modifying antirheumatic drug; csDMARD: Conventional synthetic disease-modifying antirheumatic drug; bDMARD: Biological disease-modifying antirheumatic
drug; * Median (minimum-maximum) for continuous variables; BASDAI: Bath Ankylosing Spondylitis Disease Activ ity Index; BASMI: Bath Ankylosing Spondylit is Metrology Index;
BASFI: Bath Ankylosing Spondylitis Functional Index; FACIT: Functional assessment of chronic illness therapy; HAQ-S: Health Assessment Questionnaire for spondyloart hropathies;
SF-36: Short for m 36.
Table 2. Psoriatic arthritis treatment regimen at clinic
visi t (n=961)
Treatment n %
Monotherapy with any csDMARD 407 42
Methotrexate 295 31
Sulfasalazine 62 6
Leflunomide 42 4
Hydroxychloroquine 40.4
Cyclosporine 40.4
Combination with one or more csDMARD 94 10
Monotherapy with any bDMARD 221 23
Adalimumab 73 8
Etanercept 49 5
Infliximab 35 4
Golimumab 22 2
Certolizumab pegol 26 3
Ustekinumab 10 1
Secukinumab 6 1
Combination bDMA RD with one or more
csDMARD
100 10
csDMARD: Conventional synthetic disease-modifying antirheumatic drug;
bDMA RD: Biolo gical di sease -modif ying ant irheum atic dru g.
Arch Rheumatol
6
csDMARD and bDMARD combination group
(13.3, range, 1.6 to 84.5) (Table 1).
Evaluation of the QoL in the groups revealed
that the PsAQoL score was the lowest (5, range,
0 to 20) in the group not using any medication and
the highest (5, range, 0 to 20) in the group using
bDMARD. SF-36 physical component score (PCS)
was the highest in the combination csDMARD
and bDMARD group (67.4, range, 13 to 98.8) and
the lowest in the group using csDMARD (56.8,
range, 3.8 to 100) and bDMARD (59.3, range,
6.3 to 100). SF-36 mental component scores
(MCSs) were the highest in the combination
csDMARD and bDMARD group (63.8, range,
17.3 to 91.8) and the lowest in the group using
bDMARD (55.8, range, 7.3 to 91.5). However,
there was no difference between the SF-36
PCSs and SF-36 MCSs. Interestingly, among
the subscales of SF-36, the bodily pain subscale
was found to be significantly the lowest in the
combination csDMARD and bDMARD group
(67.5, range, 12.5 to 100) and the group not using
any medication (57.5, range, 0 to 100) (Table 1).
DISCUSSION
This study evaluated the clinical characteristics,
disease activity, and the QoL of patients in Turkey
who used DMARD for PsA diseases. The rate
of incidence of inflammatory backache (57%)
and enthesopathy (48%) was higher among the
patients using bDMARD, and the presence of
peripheral arthritis (73%) was higher among the
patients using csDMARD. The VAS-pain, PtGA,
PhGA, SJC, DAS28-erythrocyte sedimentation
rate, and BASDAI scores were significantly higher
among the patients not using any medication.
Recently published guidelines of the GRAPPA
and EULAR recommend using bDMARD on
active arthritis patients with inadequate response
to NSAID and csDMARD.11 For patients with
PsA, bDMARD has shown positive effects on the
QoL by ensuring a significant improvement in
physical functions.20
An overview of the treatment options
used in our study reveals that most of the
patients with PsA underwent csDMARD
therapy, with csDMARD monotherapy being
used the most (42%). Among csDMARD users,
the most commonly used treatment was that
of MTX (31%), and the least commonly used
treatments were those of hydroxychloroquine
(0.4%) and ciclosporin (0.4%). Reason for the
low use of leflunomide, hydroxychloroquine, and
cyclosporine in the treatment of PsA, according to
the recommendations of GRAPPA and EULAR, it
is may not be only a first-line treatment but also
limited effectiveness in treatment. Among the
patients, 23% underwent bDMARD monotherapy.
The most used bDMARD was adalimumab (8%),
while the least used ones were ustekinumab (1%)
and secukinumab (1%). In our study, the reason
why use of ustekinumab and secukinumab for the
treatment of PsA was lower compared to other
biological therapies may be due to the successful
continuation of low disease activity because
of the previously initiated biological therapies.
In a multi-center study conducted in Australia
that compared DMARD treatments (n=2,948),
clinical symptoms of disease in the majority of
patients with PsA were kept under control using
csDMARD monotherapy (46%) and bDMARD
monotherapy (19%).21
As seen in previous studies, difficulties in
early diagnosis can cause a prolonged treatment
process and delay in initiating early treatment.
Thus, patients diagnosed at a later age tend to
experience more damage and higher disease
activity.22 In a country-wide study in Denmark,
the delay in diagnosis for patients with PsA
was found to be 56 months (4.6 years).23 In
this study, we determined that the delay in
diagnosis for patients with PsA was 2.9±4.5
years. The average time between the onset of
PsA and its diagnosis and the average duration
of symptoms were 9.6±8.7 and 6.7±7.1 years,
respectively, and these were significantly higher
among patients using combination csDMARD
and bDMARD (mean±SD: 11.5±8.2 and 8.7±6.8
years, respectively). This shows that as the
beginning of treatment is delayed, there is greater
need for biological treatment to regulate the
disease activity. One of the reasons for the delay
in diagnosis is the long-term follow-up of patients
with psoriasis before establishing the diagnosis of
PsA and focusing more on skin findings.
The DAPSA is a useful instrument that enables
the assessment of the treatment response level
and disease activity in PsA.13 ,24 In the literature,
a study using DAPSA and clinical DAPSA for
7
Patients with psoriatic arthritis using biological and conventional synthetic DMARDs
evaluating disease activity determined that
while the disease activity was moderate among
patients undergoing csDMARD monotherapy and
combination, the average disease activity was in
the “remission” stage among those undergoing a
combination csDMARD and bDMARD therapy
or a bDMARD monotherapy.25,26 In agreement
with these findings, our study determined that the
average disease activity among patients not using
any medication and those undergoing csDMARD
monotherapy was higher compared with that of
patients undergoing combination csDMARD and
bDMARD therapy or a bDMARD monotherapy.
Similarly, according to the DAS28 criteria, it
was observed that most patients were kept under
control superiorly with bDMARD monotherapy
or any combination with csDMARD. This shows
that bDMARDs are effective in suppressing the
parameters associated with disease activity.27
Presence of enthesitis is known to cause
increased morbidity by causing erosion in the
joints of patients with PsA.28 In this study, we
determined that most of the patients had enthesitis
(66%). Our study had a higher prevalence of
enthesitis compared with previously conducted
studies.29,3 0 While it was significantly higher
among the patients using combination DMARDs
(51%), the prevalence of enthesitis was the lowest
in those not using any medication. This shows
that bDMARDs are required to suppress enthesitis
and disease activity in patients with PsA, by the
addition of bDMARD to csDMARD. Previous
studies report that while NSAIDs and csDMARDs
are the first option in the treatment of enthesitis,
their effects are limited. In contrast, there is
evidence that bDMARDs are effective in the
treatment of enthesitis in PsA.31-3 4
Because of the heterogeneity and complexity
of PsA, it is difficult to clinically evaluate the
patients. Patients with PsA experience functional
impairment and lower QoL, which is why global
evaluation of patients with PsA essentially
involves a description of both the physical and
psychological aspects.35,36 In agreement with the
previously performed studies, we obtained lower
scores among patients who used combination
csDMARD and bDMARD in the physician and
patient global evaluations.37
Our analysis showed that patients with PsA
have lower SF-36 physical and mental scores and
lower health-related QoL scores compared with
the general population.38 In a study conducted by
Gottlieb et al.,39 SF-36 PCSs in patients with PsA
were similar to the ones reported in the literature,
while the SF-36 MCSs were lower. In a study
conducted in the general population in Norway, a
comparison of patients with PsA using bDMARD
with those using csDMARD revealed that the
scores for the bodily pain, vitality, physical role,
and general health perception subscales of SF-36
showed greater improvement.40 In this study, we
did not find any significant difference between
the SF-36 PCSs and MCSs. However, the score
for the general bodily pain subscale of SF-36 was
the highest among the patients using combination
cDMARDs and bDMARDs and the lowest among
those not using any medication.
The HAQ is a questionnaire that evaluates
the functionality of patients based on their
pain and ability to perform daily life activities.41
HAQ for the spondyloarthropathies (HAQ-S)
is a questionnaire developed specifically for
individuals with spondyloarthropathies.42 Recent
studies show that the treatments performed
with different agents ensure the improvement
of rheumatic symptoms in patients with PsA.
When biological treatments were compared with
csDMARDs in patients with PsA, the HAQ scores
were found to be significantly lower.43 However, in
our study, no significant difference was observed
in the DMARDs in terms of their associated HAQ
and HAQ-S scores.44
Limitations of our study included the fact
that it was a cross-sectional, observational study,
meaning that the present data included the
evaluation of the disease for only a certain period
in patients with a prolonged disease state. For this
reason, the factors that affected the results of the
study may have not been fully identified. Another
limitation was that this study included patients
using csDMARD and bDMARD and represented
a majority of PsA cases. However, patients who
needed to use NSAID and corticosteroids are
monitored as part of general practice and may
be included into the treatment program for
only a brief period, which is why they were not
included in the study. The strengths of this study
included the fact that it is a multi-center study
covering all regions of Turkey and that it included
a large database of patients. It also provided
the opportunity to examine the relevant clinical
Arch Rheumatol
8
characteristics and QoL between the patients who
used DMARDs and those who did not use any
medication.
In conclusion, in our study, patients with PsA
were successfully treated with both csDMARD
and bDMARD monotherapy. Both treatments
have lowered the disease activity and positively
influenced the QoL in patients with PsA.
Combinations of csDMARDs and bDMARDs
were preferred in cases in which the disease
activity was still high or increased. Because of the
highest efficacy of the combined treatment, we
highly suggest increasing the number of patients
on combined treatment.
Disclaimer
This disclaimer informs readers that the views,
thoughts, and opinions expressed in the text belong
solely to the author, and not necessarily to the author’s
employer, organization, committee or other group or
individual or previous related publications.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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