Next, Dr. Orbai discussed the CONTROL strategy trial. This trial compared the initiation of adalimumab with increased dosing of methotrexate in patients with PsA for whom 15 mg of methotrexate weekly had proved inadequate.
In the study’s initial part, patients on 15 mg of methotrexate per week were randomized to either add 40 mg of adalimumab every other week to their regimen or to have their dose of methotrexate increased to 20–25 mg per week.
In the second phase of the trial, patients in the adalimumab plus methotrexate group who responded to this combination discontinued methotrexate. Patients in this group who did not respond had adalimumab increased to 40 mg per week. In the methotrexate monotherapy group, patients who responded to the increased dosing continued methotrexate monotherapy, and patients who did not respond were transitioned to the addition of 40 mg of adalimumab every other week.
The results: Several findings are of note. First, more patients for whom 15 mg of methotrexate weekly proved inadequate achieved minimal disease activity at week 16 with the addition of adalimumab than with methotrexate dose escalation (40% vs. 13%). Among adalimumab responders, the withdrawal of methotrexate still allowed 80% of patients to maintain minimal disease activity through week 32. Among the patients who responded to the increase in methotrexate dosing, continuation of methotrexate kept 67% in minimal disease activity through week 32.
Also, Dr. Orbai pointed out that escalation of methotrexate dosing did not lead to minimal disease activity for most patients. However, the addition of adalimumab for these patients may help, indicating it’s often not too late to add a TNF inhibitor. She also said switching from biweekly to weekly adalimumab is helpful for only about 30% of patients. Thus, transitioning to a different medication is likely more appropriate.2
Conflicting evidence exists as to whether PsA is associated with an increased risk of all-cause mortality compared with the general population. However, a clear association exists between cardiovascular disease & psoriasis.
Regarding consequences of long-term PsA, conflicting evidence exists as to whether PsA is associated with an increased risk of all-cause mortality compared with the general population. However, a clear association exists between cardiovascular disease and psoriasis. With this finding in mind, joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation indicate the risk for cardiovascular disease should be multiplied by 1.5 when using a risk calculator if the patient has psoriasis with at least 10% body surface area involvement or qualifies for systemic therapy or phototherapy. These guidelines also recommend screening for comorbidities, such as diabetes, hypertension and hyperlipidemia.
