About one in five patients with early psoriatic arthritis met the newly proposed Group for Research and Assessment of Psoriasis and Psoriatic Arthritis criteria for complex-to-manage disease, while substantially fewer met the more stringent European Alliance of Associations for Rheumatology definitions for difficult-to-manage or treatment-refractory disease. Patients who met any of these definitions consistently reported worse long-term patient-reported outcomes than those who did not.
Researchers analyzed data from the Dutch Southwest Early Psoriatic Arthritis cohort, a multicenter, prospective observational study of 885 newly diagnosed, disease-modifying antirheumatic drug-naïve patients with psoriatic arthritis enrolled between 2013 and 2023. The investigators retrospectively applied the 2025 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) definitions for complex-to-manage (C2M) and treatment-refractory (TR) disease and the 2025 European Alliance of Associations for Rheumatology (EULAR) definitions for difficult-to-manage (D2M) and treatment-refractory disease. Patients were followed for a mean of 40 months.
The primary outcome was the frequency of patients meeting each definition. Secondary objectives included comparing baseline characteristics, evaluating the timing of meeting each definition, and assessing longitudinal patient-reported outcomes, including disability, pain, fatigue, and global health.
Overall, 20% of patients fulfilled the GRAPPA-C2M definition, compared with 4% who met the EULAR-D2M definition, 4% who met the EULAR-TR definition, and 1% who fulfilled the GRAPPA-TR definition during follow-up. The broader GRAPPA-C2M criteria identified patients earlier in the disease course, whereas the EULAR-D2M, EULAR-TR, and GRAPPA-TR criteria identified progressively smaller groups with more advanced and persistent disease.
Patients meeting any of the definitions were more likely than the overall study population to be female and have a higher body mass index, longer symptom duration, greater skin involvement, and enthesitis at baseline. Across all definitions, failure to achieve minimal disease activity was the most common indicator of persistent disease.
Longitudinal analyses showed that patients meeting the GRAPPA-C2M, EULAR-D2M, EULAR-TR, or GRAPPA-TR definitions consistently reported greater disability, worse global health, more pain, and greater fatigue throughout follow-up than patients who did not meet these criteria, indicating a sustained disease burden.
The authors noted several limitations. The new GRAPPA and EULAR definitions were applied retrospectively using observational data rather than prospectively. Some criteria, including disease perception, were assessed using proxy measures, and the exclusion criterion for alternative explanations of symptoms could not be fully applied to the treatment-refractory definitions. In addition, all patients were enrolled at Dutch clinical centers, which may limit the generalizability of the findings.
The findings suggest that the new GRAPPA and EULAR criteria identify distinct subgroups of patients with increasing disease burden and may help physicians recognize patients at risk for more persistent disease, although the authors noted that further refinement may improve the feasibility of applying the criteria in routine clinical practice.
"Further refinement and simplification of these criteria may improve the feasibility and consistency of identification in real-world settings, thereby supporting earlier recognition and more tailored management of patients at risk of complex or TR disease," wrote lead study author Gonul Hazal Koc, of Erasmus MC, Rotterdam, the Netherlands, and colleagues.
Disclosures: The authors reported no specific funding for this research and declared no competing interests.
Source: RMD Open