Although patients treated in the tight control group showed significant improvements in joint and skin disease activity as well as benefits in function and quality of life, the treatment also had higher costs.
“The cost per quality-adjusted life year (QALY) is borderline for cost effectiveness (the usual threshold is $50,000 or around £30,000). But as costs of therapies reduce, then it will become more cost effective,” Dr. Coates told Clinical Pain Advisor in an email.
Despite the currently high costs of treatment, Dr. Coates believes the benefits of the treat-to-target approach were significant. “There seems to be an increasing difference between standard care and tight control as you look at more stringent outcomes,” she said.
“So the difference is significant for the ACR20 (a 20% improvement in arthritis) but even more significant for the ACR70 (a 70% improvement). While all of these are useful measures, both patients and doctors are keen to achieve a really good response from their therapy which will make a significant impact on people’s function and quality of life. This means the results for ACR70 are even more impressive.”
In terms of adverse events, the tight control group also had higher rates than the standard care group, but none were unexpected or judged to be life-threatening. Overall, 20 patients (10%) reported serious adverse events – 25 events in 14 patients in the tight control group (14%) and 8 events in 6 patients in the standard care group (6%).
These were most likely due to the more intensive treatment schedule in the tight control group. Half of the serious adverse events were infections, an outcome expected in treatments that suppress the immune system.
The researchers noted that in future studies, alternative imaging techniques such as MRI might be needed to show structural damage progression in psoriatic arthritis, and longer follow-up might be appropriate. Personalizing treatment and looking at more subtypes of psoriatic arthritis would also be ideal.
“We need to know more about which therapies to use,” Dr. Coates said. “The treatment algorithm used in the study was based on expert opinion rather than true evidence. We have studies showing that individual drugs work but not which order they should be used in or who they should be used for.”
1. Coates LC, Moverley AR, McParland L, Brown S. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. The Lancet. 2015; doi: 10.1016/S0140-6736(15)00347-5.