New Recommendations for the Management of Psoriatic Arthritis

The European League Against Rheumatism (EULAR) has drawn upon 3 years of fresh research to update its guidelines for the systematic management of psoriatic arthritis for the first time since 2012.

The new document, which appears in Annals of the Rheumatic Diseases, significantly amends the 5 overarching principles of patient care that appeared in the older guidelines and recommends 10 specific treatment strategies.

“The updated recommendations propose a new algorithm which integrates all these recent developments that include drugs with novel modes of action as well as novel strategic evidence and new data on already previously addressed agents or principles,” the guideline authors wrote. “These recommendations should provide physicians who treat patients with psoriatic arthritis with a practical approach to prescribing the most appropriate treatments for patients with psoriatic arthritis based on the most recent insights.”

The overarching principles begin at the beginning, by stating that psoriatic arthritis “is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment.” They go on to state that the disease should primarily be treated by rheumatologists (with dermatologists consulting on skin problems), that treatment plans should consider safety and efficacy, that patients should share in decision making, and that the primary goal of treatment should be the maximization of function and the minimization of inflammation.

The biggest difference between the new principles and their predecessors lie in 2 areas: cost and co-morbidities. The new principles are the first to urge doctors and patients to weigh treatment price against treatment efficacy and the first to urge doctors to consider how psoriatic arthritis treatment could affect common comorbidities such as metabolic syndrome and cardiovascular disease.

The updates to the specific recommendations are far more significant, as they reflect the large number of new treatments that have appeared for psoriatic arthritis in recent years.

Still, they urge physicians to start conservatively, with local therapy and non-steroidal anti-inflammatory drugs (NSAIDs) followed, if necessary, by conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). If those treatments fail, the recommendations call for a biological DMARD (bDMARD) or a targeted synthetic DMARD (tsDMARD).

“The first bDMARD would usually be a tumour necrosis factor (TNF) inhibitor. bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate,” the guideline authors wrote. “If the first bDMARD strategy fails, any other bDMARD or tsDMARD may be used.”

The guideline authors also included a full treatment algorithm designed to guide doctors and patients step-by-step through the treatment process and direct them toward the best strategy (given the imperfect evidence that’s currently available) in virtually any scenario.

“It is important to bear in mind that, despite the evidence of their efficacy from randomized controlled trials, only expert opinion can currently define the place of the new drugs in the treatment algorithm,” the guideline authors wrote. “We are aware that this placement in the algorithm will be a topic of intense discussions in the rheumatology community. Indeed, some will contend that the Task Force has been too proactive and others will argue that it has been too limitative in terms of placement of the new drugs in the therapeutic algorithm or in terms of definitions of the target treatment population. However, the Task Force has very thoroughly considered overall efficacy (none of the new agents is numerically more efficacious than the TNFis), safety (some of the new agents indeed appear safer than TNFis) and costs, as far as comparatively available or known.”