Epidemiologic studies – highlighted as a priority for Africa – are also top of the research agenda in India.
Ashish Mathew says “we definitely need data in terms of epidemiology,” but “a huge challenge [with conducting such studies] is funding and time, because on a regular day, rheumatologists would be seeing 40 to 50 patients.”
“So if you really look at the workload, research comes pretty low in the hierarchy, and there are few of us who drive to try and do as much as we can.” He explains that research funding is available for noncommunicable diseases in India, but rheumatology “comes lower in the list in terms of funding.”
Nonetheless, Mathew says that he is in the process of setting up a PsA registry – the Vellore Inception Psoriatic diseasE Registry (VIPER) – in collaboration with Philip Conaghan, from the University of Leeds in the UK, in order to collect data on the epidemiology of the disease in India. He stresses that data from combined clinics involving both dermatologists and rheumatologists “should be a priority,” given that a large number of patients are treated at such clinics in India.
In terms of drug studies, Mathew notes that “we need to experiment with combination therapy,” because biologics are unaffordable for most patients, and those who can afford to take them can only do so for a short period of time. He explains that for those who can afford some biologic treatment, “we advocate a 6-month period of biologic, [as] that's the maximum they can afford.”
“A 6-month period of biologic, on average would cost around 100,000 Rupees [US$ 1330; € 1164], but most of these patients would be earning about 15,000–20,000 Rupees [$ 200–266; € 175–234] per month.”
He says that after an initial 6-month period, “we ask them to stop, or phase [the biologic] out, depending on how much they can afford at that point,” and “then try and combine with conventional DMARDs.” However, he notes that this strategy “is not really documented anywhere,” and requires further research to establish the best approach.
Mathew notes that research on methotrexate monotherapy is also needed, given that “when you’re in a situation where you don't have any choice but methotrexate, it's kind of your first line go-to drug.”
He remarks that one study conducted at Nizam’s Institute of Medical Sciences in Hyderabad, India, found that among PsA patients treated with methotrexate at a dose of at least 15 mg/week (average 17.5 mg/week), with targeted escalation every 4–12 weeks, approximately 60% achieved minimal disease activity (MDA), providing some support for this approach. However, “I think we need more data in terms of methotrexate,” he says.
And Mathew thinks that defining the most appropriate treatment target is another important avenue of research in the Indian setting.
“Treat-to-target, MDA, and the very low disease activity state are great [targets] and I [aim for them] when given the chance,” but “in situations with resource limitation,” other targets may be more appropriate, he says. Mathew gives the example of patient acceptable symptom state (PASS) score, which he thinks is important to investigate further as a tool to measure treatment effectiveness in India.
“For instance, [using the] example of pain perception, [this] may be totally different in the Western world as compared to somebody from India,” so “I think the patient’s perspective is very important” when evaluating treatment strategies for PsA, he says.
“I would use MDA as the gold standard, but […] the socio-cultural factors often get missed out when we talk about treat-to-target and that’s a framework which I would love to work around and figure out what are the real targets when I treat a patient with the limited drugs I have.”