The Tight Control of Psoriatic Arthritis (TICOPA) study recruited 206 patients with recent onset psoriatic arthritis (PsA). They were randomized 1:1 to tight control or standard care. Patients in the tight control arm were reviewed 4 weekly and if they did not fulfil the MDA (minimal disease activity) criteria they had their treatment escalated. Patients in the standard care arm were reviewed every 12 weeks and were treated by their usual rheumatologist. The primary outcome was ACR20 (20% improvement in American College of Rheumatology criteria) at 48 weeks and the odds of achieving this were significantly higher in the tight control arm (OR 1.91, p=0.0392) using intention to treat analysis. The odds of achieving ACR50, ACR70 and PASI75 (psoriasis area and severity index) were all significantly higher for the tight control group. Improvements were also seen in patient reported outcomes including physical function (HAQ), quality of life (PsQOL) and also BASDAI (Bath ankylosing spondylitis index) and BASFI (Bath ankylosing spondylitis functional index) for those with axial disease.
No difference in the radiographic progression between the two arms was detected but the mean change in modified van der Heijde-Sharp score was zero in both groups. The tight control arm was associated with increased rates of adverse events and serious adverse events which may be due to the more rapid escalation of DMARD (disease modifying anti rheumatic drug) therapy. A cost effectiveness analysis was included in the TICOPA trial. The mean cost per patient in the tight control group was approximately twice that of the patients in the standard care group (£4198 vs £2000). Using mean quality-adjusted-life-years, the study found an incremental cost-effectiveness ratio of £53,948 per quality-adjusted life-year. Sensitivity analyses were performed to account for a reduction in visits once patients were consistently in MDA and did yield levels of around £30,000. As a result of this publication, the latest update of the EULAR Recommendations for the Management of PsA, presented at the 2015 EULAR meeting in Rome, have recommended that a treat to target approach is used for the management of PsA.
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