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Enthesitis in Psoriatic Arthritis Increases Disease Burden, Decreases Treatment Satisfaction


Patients with psoriatic arthritis with enthesitis are more likely to have severe disease than patients without enthesitis, and they and their physicians are less likely to be satisfied with their treatments.

Although patients with psoriatic arthritis (PsA) and enthesitis—inflammation at the sites where tendons on ligaments insert into the bone—experience higher disease burden than patients without enthesitis, they are not more likely to receive advanced therapies, according to research published in Rheumatology and Therapy.

The researchers conducted a cross-sectional survey of 454 rheumatologists and 238 dermatologists, and their 3157 patients with PsA in Australia, Canada, Japan, the United States, and 5 countries in the European Union (EU5).

“Enthesitis has been suggested as an important indicator of PsA disease severity,” the authors explained. They added that past research has shown patients with PsA with enthesitis have worse patient-reported outcomes and that enthesitis usually needs intense treatment because it is considered resistant to disease-modifying antirheumatic drugs (DMARDs). However, the “impact of enthesitis on physician satisfaction with PsA treatments has not been well characterized.”

Of the 3157 patients, 2951 did not have enthesitis and 205 had enthesitis. The physicians reported that enthesitis was mild in 54.0%, moderate in 41.3%, and severe in 4.6% of the entire sample. For the most part, the demographics between the 2 groups of patients with and without enthesitis were similar; however, less than half (47.2%) of patients were likely to be working full time compared with 58.1% of patients without enthesitis.

Physicians were more likely to rate their patients with enthesitis as having moderate to severe disease (52.2%) than their patients without enthesitis (23.2%, P < .001). Patients with enthesitis were also more likely to show a greater number of other PsA manifestations:

  • Nail psoriasis (33.2% vs 14.8%, P < .0001)
  • Dactylitis (31.7% vs 5.9%, P < .0001)
  • Sacroiliitis (10.7% vs 3.4%, P < .0001)

Patients with enthesitis were more likely to be taking medication for their pain compared with patients without enthesitis:

  1. Nonsteroidal anti-inflammatory drugs (44.4% vs 22.9%, P < .001)
  2. Non-opioid analgesics (10.7% vs 5.4%, P = .0045)
  3. Opioid analgesics (8.3%) vs 1.9%) P < .0001)

Similar proportions of both groups were receiving targeted synthetic DMARDs (12.2% with enthesitis vs 9.3% without, P = .1754) and biologic DMARDs (58.5% vs 58.4%, P = 1.000); however, patients with enthesitis were taking conventional synthetic DMARDS at a higher percentage (44.9% vs 34.2%, P = .0024). While 84.4% of physicians were satisfied with disease control in the patients with PsA without enthesitis, only 57.6% of physicians treating patients with PsA with enthesitis said the same. Similarly, 79.7% of patients without enthesitis were satisfied with treatment compared with 52.2% of patients with enthesitis.

“Our findings underscore the importance of assessing patients with PsA for enthesitis and ensuring its optimal management,” the authors concluded. “Data on PsA treatment efficacy specifically for enthesitis are needed to expand treatment options for patients and physicians.”


Orbai A-M, Birt JA, Holdsworth EA, et al. Impact of enthesitis on psoriatic arthritis patient-reported outcomes and physician satisfaction with treatment: data from a multinational patient and physician survey. Rheumatol Ther. Published online October 14, 2020. doi:10.1007/s40744-020-00242-3

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