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Women with Psoriatic Arthritis Experience Higher Disease Activity and Different Treatment Response

July 15, 2021
Women with PsA may exhibit differences in disease expression and TNF inhibitor treatment response. How to translate new research findings into meaningful treatment options.

Women with peripheral psoriatic arthritis showed higher levels of disease activity and lower remission rates compared to men, based on data from more than 1,000 patients.

Psoriatic arthritis (PsA) tends to occur in men and women in equal ratios but research also indicates that women with PsA report more pain, fatigue, joint count activity, and functional impairment, wrote Mehmet Tuncay Duruöz, MD, of Marmara University School of Medicine, İstanbul, Turkey, and colleagues in a recently published paper.1

We know that “diseases differ between genders in diagnosis and treatment strategies,” they stated, and understanding “gender differences in PsA with several manifestations are essential in terms of treatment, prognosis, and follow-up.”

In their cross-sectional study published in Joint Bone Spine, the researchers – led by Dr. Duruoz – identified 678 women and 360 men who were enrolled in the Turkish League Against Rheumatism Network study. Disease activity was measured using the Disease Activity Score (DAS28) and clinical Disease Activity for Psoriatic Arthritis (cDAPSA). The average age of the patients was 47.6 years for women and 46.3 years for men. The onset of disease occurred at younger than 45 years in approximately 69% of women and 77% of men.

A gender difference in psoriatic arthritis treatment response between males and females was found in a new study, with women showing less treatment response to tumor necrosis factor (TNF) inhibitors (Image: iStock).

Women with PsA Report Higher Levels of Disease Activity and Comorbidities

Overall, women had significantly higher scores on both the DAS28 and cDAPSa compared to men (P<0.05).

Psoriatic Arthritis Disease Activity in Males and Females 

Men showed a significantly lower tender joint count than women, and less pain on the visual analog scale and patient global assessment compared with women, although joint stiffness reports were similar between the sexes, the researchers noted.

In terms of DAS28 and cDAPSA, women had significantly higher disease activity scores based on the DAS28 and cDAPSA compared to men (P < 0.05) and men had approximately twice the rates of remission compared with women on both DAS28 remission (32.8% vs. 17.6%, respectively) and cDAPSA remission (13.1% vs. 7.7%, respectively). Women also were less likely to achieve minimal disease activity compared to men (15.5% vs. 22.5%).

Incidences of dactylitis, enthesitis, tenosynovitis, and inflammatory bowel disease (IBD) were similar in men and women but spondylitis was significantly more common in men.

Psoriatic Arthritis Function in Males and Females 

To assess patient outcomes of functional capacity and quality of life, the team used the Health Assessment Questionnaire (HAQ) and the Short-Form Health Survey (SF-36). Overall scores on the HAQ were significantly higher in women compared with men. SF-36 subscores and summary scores were lower in women compared to men, with women reporting more anxiety, depression, fatigue, and fibromyalgia.

Women were less likely to achieve minimal disease activity compared with men (15.5% vs. 22.5%), although the percentage of patients who achieved very low disease activity (VLDA) was similar between women and men (3.1% vs. 4.7%, respectively).

Study Limitations

The study was limited by several factors, including the lack of evaluation of radiographic data and the lack of data on treatment response and long-term outcomes in men vs. women. Additional studies are needed to address these areas, the researchers noted. However, these new results support data collected from previous studies, notably the increased reports of anxiety, depression, fatigue, and fibromyalgia in women with PsA, they said.

Overall, this study adds to the growing body of research on pain and sex disparities, including inflammatory conditions, with results showing overall higher levels of pain in women compared to men. PPM spoke to Editorial Advisor Tiziano Marovino, DPT, MPH, DAAIPM, to get more insight on what the findings mean for clinical practice and pain management.

 

Sex Differences in PsA Go Beyond Prevalence; Should Impact Treatment Decision-Making

“At a time in history when we want to bring people together and highlight what we have in common, we cannot escape the fact that there is a need for biodiversity, which also includes how our bodies express similar conditions differently,” Dr. Marovino dold PPM.

“The recognition that sex plays a role in symptom expression is crucial to helping understand the disease and how to prevent or treat it,” he noted. “Consistently greater differences between sexes than within sexes suggests that sex is predictive of a disease, or in this case, disease activity and clinical features.”

Further, he added, “Many of us are used to thinking about sex differences from a prevalence and incidence perspective, such that a condition or disease manifests in males more than females, or vice versa, followed by a ratio which quantifies this relationship,” Dr. Marovino noted. The current study led by Dr. Duruoz stands out by examining specific clinical manifestations that serve as a measure of disease activity and by using functional measurement instruments to capture estimates of pain, fatigue, and functional limitations, along with radiologic markers, he explained.

“We are not always accustomed to describing disease activity beyond simple epidemiologic estimates, so this study provides a glimpse into what it means to be either male or female from a disease manifestation standpoint.”

PsA Treatment Response to TNF Inhibitors Differs Between Males and Females

Dr. Duruoz’s team cited data suggesting a gender difference in treatment response between males and females as well, with women showing less treatment response to tumor necrosing factor (TNF) inhibitors that essentially block or suppress TNF, which is an important part of the inflammatory response, noted Dr. Marovino. The lack of treatment response in females to certain biologics needs further exploration to provide viable treatment options for both sexes, he said.

The key clinical message from the study is specificity, Dr. Marovino explained. “As we learn more about the distinct differences in disease expression and activity levels between subsets of the population including stratified by sex, we must then translate this information into meaningful treatment options that respect the differences in disease phenotypes within the context of sex,” he explained. “This type of study has implications for all provider types from massage and physical therapy (bodyworkers) to chiropractic and osteopathic medicine (manual practitioners), he noted.

However, as with most studies, it’s important to interpret the data from functional outcome measures with are, whether from patients of clinical reports, Dr. Marovino cautioned. “The authors allude to the imperfect relationship between an individual’s disease activity level and the measurement tool that is used to quantify the level or severity of disease activity.”

“More research into gender-specific causes that might help explain differences in how disease is expressed or manifested could be extremely helpful in eventually developing more targeted approaches to treatment of spondyloarthritic conditions,” he said. “Sex differences in disease activity, drug metabolism, genetic/epigenetic factors and the multitude of constitutional and environmental factors that could play a role in how chronic inflammatory disease evolves will need to be addressed in the future,” he added.

The study was funded by the Turkish League Against Rheumatism Association.

Last updated on: July 15, 2021
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