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Unmet needs

the PALACE programme of clinical trials.24

Ustekinumab is a human

monoclonal antibody that binds to the shared p40 subunit of interleukin-12 and IL-23, thereby blocking their biologic signalling.

Quality of care

Psoriasis and PsA patients tend to be undertreated. In the past decade, great efforts have been made in order to improve the therapeutic approach and outcomes of treatment; in this regard, a closer collaboration between rheumatologists and dermatologists has been envisaged and promoted, both in Europe and in the US. Furthermore, a greater participation of patients has been considered fundamental in the management of the disease, so that patients should be included in the assessment of their diseases as well as in the treatment decision process. These issues have been summarised in the so-called ‘Quality Movement’ in the US, including all sorts of interventions that might influence quality management of disease in general. In all fields of medicine, it has been felt that there is the need for evidence-based treatment guidelines and assessment of efficacy, monitoring on safety, overall outcome, and cost-effectiveness. In 2007, GRAPPA launched an Initiative for Quality aiming to promote ‘state of the art’ management of PsA patients, which implies early diagnosis and best treatment available, patients participation, and much more, in a single word – quality.25

Economic burden

The new developed biologic drugs are as effective as costly, and for this reason their use is currently limited in the western world countries, where different restrictions and strict criteria from the NHS and private insurance companies modulate their prescription to patients. Several pharmacoeconomic studies have been performed in order to evaluate the cost effectiveness of treatment with biologic drugs in chronic arthritis. Olivieri and colleagues recently performed an observational, longitudinal, multicentre study that evaluated PsA patients retrospectively and prospectively, and concluded that treatment with TNF antagonists is cost effective.26


confirmation of the cost-effectiveness of biologic drugs was also provided by Cawson and colleagues in their systematic review,27

and it is conceivable that similar

studies will also be performed in the future for the new biologic agents.


Despite the huge advances reached in the last 20 years in the understanding of the pathogenesis of PsA, in its diagnosis, assessment and treatment, there is still a long way to go. New effective drugs are now available, enabling physicians to influence the disabling course of the disease. The exact pathogenesis of PsA is still unknown, but the implementation of modern technologies will enable scientists and pharmaceutical companies to discover new targets and to develop new drugs in an attempt to halt the natural disabling history of this disease. l

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5. Paladini F et al. Distribution of HLA-B27 subtypes in Sardinia and continental Italy and their association with spondylarthropathies. Arthritis Rheum 2005;52:3319–21.

6. Cauli A et al. CD1 positive antigen presenting cells in psoriatic and rheumatoid arthritis. Rheumatology 2000;6:666–73.

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8. Cauli A, Mathieu A. Th17 and interleukin 23 in the pathogenesis of psoriatic arthritis and spondyloarthritis. J Rheumatol Suppl 2012;89(7):15–8.

9. Husni ME et al. The PASE questionnaire: pilot-testing a psoriatic arthritis screening and evaluation tool. J Am Acad Dermatol 2007;57:581–7.

10. Ibrahim GH et al. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol 2009;27:469–74.

11. Chandran V, Gladman DD. Toronto Psoriatic Arthritis Screening (ToPAS) questionnaire: a report from the GRAPPA 2009 annual meeting. J Rheumatol 2011;38:546–7.

12. Coates LC et al. Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study). Br J Dermatol 2013;168:802–7.

13. Cauli A et al. Patient global assessment in psoriatic arthritis: a multicenter GRAPPA and OMERACT study. J Rheumatol 2011;38:898–903.

14. Helliwell PS et al. The development of candidate composite disease activity and responder indices for psoriatic arthritis (GRACE project). Ann Rheum Dis 2013;72:986–91.

15. Gladman DD et al. Informing response criteria for psoriatic arthritis (PsA). II: Further considerations and a proposal--the PsA joint activity index. J Rheumatol 2010;37:2559–65.

16. Mumtaz A et al. Development of a preliminary composite disease activity index in psoriatic arthritis. Ann Rheum Dis 2011;70:272–7.

17. Bond SJ et al. Predictors for radiological damage in psoriatic arthritis: results from a single centre. Ann Rheum Dis 2007;66:370–6.

18. de Vlam K, Gottlieb AB, Fitzgerald O. Biological biomarkers in psoriatic disease. A review. J Rheumatol 2008;Jul;35(7):1443–8.

19. Ritchlin CT et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis 2009;68: 1387–94.

20. Salvarani C et al. Recommendations for the use of biologic therapy in the treatment of psoriatic arthritis: update from the Italian Society for Rheumatology. Clin Exp Rheumatol 2011;29: S28–41.

21. Kingsley GH et al. A randomized placebo- controlled trial of methotrexate in psoriatic arthritis. Rheumatol 2012;51:1368–77.

22. Coates LC et al. The TICOPA protocol (Tight Control of Psoriatic Arthritis): a randomized controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Muscoloskeletal Disord. 2013 Mar 21;14:101.

23. Schafer PH et al. Apremilast, a cAMP phosphodiesterase-4 inhibitor, demonstrates anti- inflammatory activity in vitro and in a model of psoriasis. Br J Pharmacol 2010;159:842–55.

24. Schett G et al. Oral apremilast in the treatment of active psoriatic arthritis: Results of a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2012;64:3156–67.

25. Boehncke WH et al. Initiative for quality in psoriasis and psoriatic arthritis. J Rheumatol 2008;35:1431–3.

26. Olivieri I et al. The psoriatic arthritis cost evaluation (PACE) study: a cost-of-illness study on tumor necrosis factor inhibitors in psoriatic arthritis patients with inadequate response to conventional therapy. Rheumatology (Oxford) 2008,47:1664–70.

27. Cawson M et al. Systematic review, network meta-analysis and economic evaluation of biologic therapy for the management of active psoriatic arthritis. BMC Musculoskelet Disord 2014; 20:15–26.


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