About 30% of patients with psoriasis have psoriatic arthritis (PsA), a complex, multi-faceted, chronic, inflammatory musculoskeletal and skin disease for which the treatment has changed considerably over the past few years.1 Biosimilars and other new drugs have become a therapeutic turning point for many patients suffering from rheumatic illnesses, including PsA. The treatment of PsA includes a variety of options, some of which are off-label therapies.
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In 2019, the ACR and the National Psoriasis Foundation (NPF) published their first joint guideline for treating psoriatic arthritis. Review it at https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Psoriatic-Arthritis.2 The ACR/NPF guideline defined active PsA based on activity in any features (i.e., actively inflamed joints, dactylitis, enthesitis, axial disease, active skin and/or nail involvement, and/or extra-articular manifestations, such as uveitis or inflammatory bowel disease), based on whether the manifestations are clinically significant and attributable to psoriatic arthritis. Although the impact of PsA on quality of life is comparable to that of rheumatoid arthritis (RA), significantly fewer resources exist for patients living with PsA than for patients with RA.3 The disparities in health resources for PsA include:
- Limited research;
- Misunderstood symptoms or inadequate treatment;
- Delayed diagnoses;
- Lack of understanding of how the disease can impact quality of life; and
- Conflicting information that impacts the management of the disease.
Disease Management Decision
The ACR/NPF guideline was created to assist healthcare providers and their patients in making challenging disease management decisions and select optimal therapy. Although the number of new therapies available for the treatment of PsA has increased, limited comparative efficacy and effectiveness evidence exists to inform treatment decisions.
The treat-to-target approach started as a strategy for managing heart disease and diabetes and is now the most widely accepted treatment approach for RA and other inflammatory diseases.4 However, treat to target is not the standard of care in PsA; it is a conditional recommendation, based on low- to very-low-quality evidence, in the ACR/NPF guideline.
Treatments for PsA include traditional or conventional disease-modifying anti-rheumatic drugs (DMARDs); biologic therapies, such as tumor necrosis factor (TNF) inhibitors, interleukin (IL) 17 receptor antagonists, and IL-12 and IL-23 inhibitors; and targeted new oral agents, including a phosphodiesterase-4 inhibitor (PDE4) and a Janus kinase (JAK) inhibitor. Additional therapies approved for psoriasis but not yet approved for PsA include an IL-17 receptor antagonist (brodalumab) and two IL-23 inhibitors (tildrakizumab and risankizumab). (Note: For detailed info for each drug, see Table 1 and Table 2 below.)
In addition to pharmacologic recommendations, the ACR/NPF guideline conditionally recommends the following non-pharmacologic therapies: low-impact exercise (e.g., tai chi, yoga, swimming), physical therapy, occupational therapy, weight loss in patients who are overweight or obese, massage and acupuncture. Smoking cessation was strongly recommended because it is associated with cardiovascular disease and worse treatment outcomes.
Summary by Drug Class
Drug Class: PDE4 inhibitor