Increased activity of psoriatic arthritis, impact observed in low-income countries

Patients with psoriatic disease who live in low-income countries showed the highest disease activity and impact despite similar use of biologic drugs as in higher-income regions.

Higher disease activity and impact of psoriatic arthritis (PsA) has been found in patients living in countries with the lowest gross domestic product (GDP) per capita. The findings were published in Rheumatic and 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, choices of health care providers and patient factors.

Previous research has shown a significant reduction in the implementation of cost-effective interventions and the provision of quality care for cardiovascular disease, which accounts for 30% of annual global mortality, in low-income countries. Specific to rheumatology, patients from wealthier countries showed lower disease activity for conditions such as rheumatoid arthritis, although results regarding disease impact have been cited by researchers as conflicting.

“PSA is a complex inflammatory disease that has a wide range of clinical patterns and differing management recommendations, which can lead to disparities between countries. In PA, given the lack of large cohorts or real-world datasets, health disparities between countries have been little explored,” the study authors said.

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

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

Participants were assessed for disease activity via the measures of disease activity in PsA (DAPSA) and minimal disease activity (MDA) and for disease impact by the PsA disease impact questionnaire (PsAID12). The use of biologic disease-modifying antirheumatic drugs (bDMARDs) was analyzed by country and compared across the 3 tertiles of GDP per capita by parametric and non-parametric tests.

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

Patients from countries with the lowest GDP per capita were found to have the highest disease activity of the 3 tertiles, with DAPSA remission and MDA, respectively, in the lowest tertile, at 7, 0% and 18.4% against 29.1% and 49.5% in the middle. tertile and 16.8% and 41.3% in the top tertile (all P

The impact of disease was also worse in the bottom tertile of GDP per capita. A PsAID12 score of 4.0 or less (threshold for acceptable patient symptoms) was achieved in 64.0%, 80.8%, and 74.6% of patients in the low, middle, and low GDP/capita tertiles. high, respectively.

The use of bDMARDs was particularly similar across all 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 countries with low GDP/capita (P = 0.004)—highlighting an unmet need in the management of PAs in patients with more severe disease in low-income countries.

The researchers concluded that further analyzes are warranted to confirm the results of the cross-sectional study. “If confirmed, the directions for the future include policy measures aimed at generalizing access to medicines, patient education programs and the dissemination of management recommendations. Such projects would promote more equity in rheumatology health care.


Lucasson F, Kiltz U, Kalyoncu U, et al. Health care disparities 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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