The ACR and the National Psoriasis Foundation (NPF) have published their first joint Guideline for the Treatment of Psoriatic Arthritis (PsA). The guideline, to be published in the January 2019 issues of Arthritis & Rheumatology, Arthritis Care & Research and the Journal of Psoriasis and Psoriatic Arthritis, will serve as an aid to practitioners managing active PsA in patients.1
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[Editor’s note: The reference below was updated on Jan. 3, 2019, to reflect the print publication information.]
What the Guideline Includes
The management of active PsA in patients who are treatment naive and those who continue to have active PsA despite treatment is covered in the guideline, which includes strategies for optimizing therapy. The evidence-based guideline addresses use of oral, small molecule (OSM) drugs, tumor necrosis factor inhibitors (TNFi), interleukin (IL) 12/23 inhibitors, IL-17 inhibitors, CTLA4-Ig (abatacept) and a JAK inhibitor (tofacitinib).
Additionally, the guideline includes recommendations for management of patients with psoriatic spondylitis and predominant enthesitis, as well as treatment in the presence of concomitant inflammatory bowel disease (IBD), diabetes or serious infection. The presence of these concomitant conditions, according to the guideline, influences decisions about optimal therapy. Recommendations are included for a treat-to-target strategy, vaccinations and nonpharmacologic therapies. The intention is to help providers work with patients in selecting appropriate therapy in common clinical scenarios.
First-Line Therapy with TNF Inhibitor
Both the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) released recommendations for PsA in 2015.2,3 One significant difference in this new guideline from those developed by EULAR and GRAPPA: The recommendation to use a TNFi over an OSM agent (i.e., methotrexate) for patients who are treatment naive and have relatively active disease.
“The GRAPPA recommendations suggest that a physician bypass traditional DMARDs [disease-modifying anti-rheumatic drugs] and go to biologic agents in a case where there are bad prognostic signs. But this guideline recommends using anti-TNF agents first in people with active psoriatic arthritis,” says Dafna D. Gladman, MD, professor of medicine at the University of Toronto and Toronto Western Hospital, Ontario, and a member of the guideline’s core team.
“Many rheumatologists may already be doing what is recommended in the guideline, which will just confirm their actions,” she says. “But for some, the recommendation [will be surprising].”
“Methotrexate or other OSMs can be used first for people with less severe disease,” says Alexis Ogdie, MD, MSCE. Dr. Ogdie is assistant professor of medicine at the Hospital of the University of Pennsylvania, Philadelphia, and another member of the guideline’s core team.