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Greater Psoriatic Arthritis Activity, Impact Observed in Low-Income Countries


Patients with psoriatic disease who live in low-income countries exhibited the highest disease activity and impact despite similar usage of biologic drugs to that of higher-income areas.

Higher disease activity and impact of psoriatic arthritis (PsA) was found among patients living in countries with the lowest gross domestic product (GDP) per capita. Findings were published in Rheumatic & Musculoskeletal Diseases.

Low-income countries have been shown to be disproportionately affected by health equity gaps that are exacerbated by barriers such as access to care, financial restrictions, health care provider choices, and patient-related factors.

Prior research has shown significantly reduced implementation of cost-effective interventions and provision of quality care for cardiovascular diseases, which account for 30% of annual global mortality, in low-income countries. Specific to rheumatology, patients from wealthier countries have exhibited lower disease activity for conditions such as rheumatoid arthritis, although results regarding disease impact were cited by researchers to be conflicting.

“PsA is a complex inflammatory disease that presents a wide spectrum of clinical patterns and differing management recommendations, which may lead to country disparities. In PsA, given the lack of large cohorts or real-world data sets, health disparities across countries have been little explored,” said the study authors.

They conducted a cross-sectional analysis of 13 countries from the Remission/Flare in PsA study to explore the differences between countries in PsA outcomes and treatment choices, as well as the role of GDP per capita in these differences. Countries were classified into tertiles by GDP per capita, according to the International Monetary Fund 2017 database, with a total of 439 consecutive adult patients with PsA (mean age, 52.3 years; mean disease duration, 10.1 years; 50.6% male) included in the analysis:

  • Lowest tertile: Brazil, Turkey, Russian Federation, Romania, and Estonia
  • Middle tertile: Spain, Italy, United Kingdom, and France
  • Highest tertile: Canada, Germany, United States, and Singapore

Participants were assessed for disease activity via Disease Activity in PsA (DAPSA) and Minimal Disease Activity (MDA) metrics and for disease impact by the PsA Impact of Disease questionnaire (PsAID12). Use of biological disease-modifying antirheumatic drugs (bDMARDs) was analyzed per country and compared between the 3 tertiles of GDP per capita by parametric and nonparametric tests.

Additional analyses were performed to explore the percentage of patients with significant disease activity (DAPSA > 14) and no ongoing bDMARD prescription.

Patients of the lowest GDP per capita countries were found to exhibit the highest disease activity of all 3 tertiles, with DAPSA remission and MDA, respectively, in the lowest tertile shown to be 7.0% and 18.4% vs 29.1% and 49.5% in the middle tertile and 16.8% and 41.3% in the highest tertile (all P < .001).

Disease impact was also worst in the lowest tertile of GDP per capita. A PsAID12 score of 4.0 or less (threshold of the patient acceptable symptom state) was achieved in 64.0%, 80.8%, and 74.6% of patients in the low, middle, and highest GDP/capita tertiles, respectively.

Use of bDMARDs was notably similar across the tertiles (overall mean, 61%). The overall rate of patients with moderate/high disease activity (DAPSA > 14) and no bDMARD use was 18.5%, which was higher in lower GDP/capita countries (P = .004)—highlighting an unmet need in PsA management for patients with more severe disease in low-income countries.

Researchers concluded that further analyses are warranted to confirm findings of the cross-sectional study. “If confirmed, directions for the future include political measures to generalize access to drugs, patient education programs, and dissemination of management recommendations. Such projects would promote more equity in health care in rheumatology.”


Lucasson F, Kiltz U, Kalyoncu U, et al. Disparities in healthcare in psoriatic arthritis: an analysis of 439 patients from 13 countries. RMD Open. 2022;8(1):e002031. doi:10.1136/rmdopen-2021-002031

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