Introduction
Psoriatic arthritis (PsA) is a multifaceted inflammatory condition characterized by peripheral arthritis, enthesitis, dactylitis, and axial involvement, often occurring alongside cutaneous psoriasis. The management of early PsA has undergone a paradigm shift toward a treat-to-target (T2T) approach, emphasizing the importance of achieving low disease activity or remission as quickly as possible. The concept of a “window of opportunity”—a period early in the disease course where aggressive intervention can fundamentally alter the long-term radiographic and functional trajectory—is widely accepted in rheumatoid arthritis and is increasingly applied to PsA. However, the optimal first-line strategy remains a subject of intense debate among clinicians. While conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), specifically methotrexate (MTX), remain the standard first-line therapy, the early introduction of biologic DMARDs (bDMARDs) has been proposed as a means to achieve deeper and more rapid responses.
Highlights
The GOLMePsA trial provides critical insights into the comparative efficacy of aggressive initial regimens. Key takeaways include:
- The addition of golimumab to a combination of methotrexate and corticosteroids did not result in a statistically significant difference in the primary endpoint of PASDAS at week 24 compared to methotrexate and corticosteroids alone.
- A significantly higher proportion of patients in the methotrexate-only arm required rescue corticosteroids (49% vs. 21%), suggesting a robust steroid-sparing effect of early golimumab use.
- Both treatment strategies led to substantial clinical improvements, underscoring the high efficacy of utilizing methotrexate and corticosteroids as an intensive induction regimen in treatment-naïve patients.
Background and Clinical Context
Early diagnosis and intervention are paramount in PsA to prevent irreversible joint damage and maintain quality of life. Current EULAR and GRAPPA guidelines suggest starting with csDMARDs, but there is growing evidence that some patients may benefit from earlier biologic therapy, particularly those with poor prognostic factors. The GOLMePsA study (Effect of a treatment strategy utilizing golimumab, methotrexate, and corticosteroids versus methotrexate and corticosteroids in early, untreated psoriatic arthritis) aimed to address the uncertainty regarding whether triple therapy—combining a TNF inhibitor (golimumab), a csDMARD (MTX), and corticosteroids—is superior to a potent dual-therapy regimen in treatment-naïve patients.
Study Design and Methodology
The GOLMePsA trial was a single-center, double-blind, randomized, placebo-controlled, parallel-group study conducted in the United Kingdom. It enrolled 84 adults with active, treatment-naïve PsA who had been diagnosed within the previous 24 months. Participants were randomized 1:1 to one of two groups:
Combination Therapy Group
Participants received subcutaneous golimumab (50 mg every 4 weeks) plus oral methotrexate (escalated to 25 mg weekly within 28 days) and a baseline dose of intramuscular methylprednisolone (120 mg).
Control Group
Participants received a placebo injection every 4 weeks plus oral methotrexate (escalated to 25 mg weekly) and a baseline dose of intramuscular methylprednisolone (120 mg).
The primary endpoint was the mean Psoriatic Arthritis Disease Activity Score (PASDAS) at week 24. PASDAS is a comprehensive composite index that includes tender and swollen joint counts, patient global assessment, physician global assessment, skin involvement, dactylitis, enthesitis, and inflammatory markers (CRP). This endpoint provides a more holistic view of the disease than simple joint counts.
Key Findings
The study results, published in The Lancet Rheumatology, revealed several nuances in early PsA management. Between 2015 and 2022, 84 patients were randomized (43 to the golimumab group and 41 to the placebo group). The mean age was 42.5 years, and the population was relatively balanced in terms of gender.
Primary Endpoint: PASDAS at Week 24
At week 24, the unadjusted mean PASDAS was 2.70 in the golimumab plus MTX group and 3.09 in the placebo plus MTX group. The adjusted difference was -0.55 (95% CI -1.12 to 0.03; p=0.064). While the golimumab group trended toward better outcomes, the difference did not reach the threshold for statistical significance. This finding suggests that for the general population of early PsA patients, the addition of a TNF inhibitor to an optimized MTX and steroid regimen may not offer a dramatic advantage in the short term regarding composite disease activity scores.
Secondary Findings and Steroid Rescue
A notable secondary finding was the use of rescue corticosteroids. Participants in the placebo plus MTX group were significantly more likely to require additional methylprednisolone before week 24 (49% vs. 21%; odds ratio 0.28). This indicates that while the final PASDAS scores were similar, the golimumab group achieved their status with less reliance on systemic steroids, which has important implications for long-term safety and metabolic health.
Safety and Tolerability
The safety profiles were largely comparable between the two groups. Adverse events occurred in 95% of the golimumab group and 93% of the placebo group. However, the golimumab group experienced a higher frequency of laboratory abnormalities (such as liver enzyme elevations) and infections. Crucially, no deaths or serious unexpected adverse events were reported, confirming the general safety of these intensive induction strategies.
Expert Commentary
The GOLMePsA trial highlights a critical reality in rheumatology: the “standard of care” (methotrexate) when optimized with corticosteroids and rapid dose escalation is a formidable comparator. The high efficacy of the control arm likely contributed to the study’s failure to reach statistical significance on the primary endpoint. In many previous trials where biologics showed clear superiority, the control arm often used less aggressive MTX dosing or lacked the initial corticosteroid boost.
From a mechanistic perspective, the rapid suppression of inflammation provided by IM methylprednisolone likely “leveled the playing field” in the early months of the trial. For clinicians, this reinforces the value of MTX and steroids as a cost-effective and potent induction therapy. However, the significantly lower need for rescue steroids in the golimumab group cannot be ignored. For patients at high risk of steroid-related complications (e.g., those with diabetes or obesity), the early introduction of a biologic might be justified primarily as a steroid-sparing measure.
The study’s limitations include its single-center design and a relatively small sample size, which may have limited the power to detect smaller differences in composite scores. Furthermore, the 24-week primary endpoint might be too early to see the full divergence in radiographic progression or long-term joint preservation that biologics might offer.
Conclusion
The GOLMePsA trial demonstrates that both golimumab plus MTX and MTX alone, when combined with initial corticosteroids, are highly effective strategies for inducing low disease activity in early, untreated psoriatic arthritis. While the addition of golimumab did not significantly improve the PASDAS score compared to the intensive control regimen at 24 weeks, it did provide a significant steroid-sparing benefit. These findings support the current practice of starting with optimized methotrexate and steroids in most patients, while reserving biologics for those with inadequate responses or specific contraindications to prolonged steroid exposure. Future research should focus on identifying biomarkers that can predict which subset of patients truly requires triple therapy from the outset to prevent long-term disability.
Funding and Clinical Registry
The study was funded by Janssen Biologics BV. It is registered with EudraCT, number 2013-004122-28.
References
- De Marco G, Hensor EMA, Helliwell PS, et al. Effect of a treatment strategy utilising golimumab, methotrexate and corticosteroids versus methotrexate and corticosteroids in early, untreated psoriatic arthritis (GOLMePsA): a single-centre, double-blind, parallel-group, randomised controlled trial. Lancet Rheumatol. 2025;7(11):e776-e788.
- Coates LC, Helliwell PS. Psoriatic arthritis: state of the art review. Clin Med (Lond). 2017;17(1):65-70.
- Smolen JS, Schöls M, Braun J, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2018;77(1):3-17.
