American College of Rheumatology and National Psoriasis Foundation Issue Joint PsA Guidelines

The American College of Rheumatology and National Psoriasis Foundation have issued a set of recommendations for the management of psoriatic arthritis (PsA).

The guidelines cover options for treatment-naïve PsA patients as well as those whose PsA persists despite treatment and include pharmacologic and nonpharmacologic therapies, and symptomatic treatments.

The recommended pharmacologic therapies include:

• oral small molecules (OSMs)—methotrexate (MTX), sulfasalazine, cyclosporine, leflunomide, and apremilast
• tumor necrosis factor inhibitors (TNFis)—etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol
• interleukin-12/23 inhibitor (IL-12/23i)—ustekinumab
• IL17i—secukinumab, ixekizumab, and brodalumab
• CTLA4-Ig—abatacept
• JAK inhibitor—tofacitinib

Non-pharmacologic therapies include physical therapy, occupational therapy, smoking cessation, weight loss, massage therapy, and exercise. The researchers note that many other non-pharmacologic therapies exist, but their report only covers six.

Symptomatic treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and local glucocorticoid injections.

ACR/NPF Introduce 2018 Psoriatic Arthritis Clinical Practice Guideline – details: https://t.co/PnVZhqm1Ul pic.twitter.com/TEJnegvTuj

— American College of Rheumatology (@ACRheum) December 13, 2018

The researchers provided conditional recommendations for PsA patients naïve to treatment with OSM and other therapies. For most patients, they suggest TNFi biologic treatment over treatment with an OSM, IL-17i biologic, or IL-12/23i biologic. OSM is recommended over an IL-17i biologic or IL-12/23i biologic. MTX is suggested over NSAIDs, and IL-17i biologics are recommended over IL-12/23i biologics.

For patients whose PsA remains active despite OSM treatment, the guidelines recommend TNFi biologic therapy instead of a different OSM, an IL-17i biologic, an IL-12/23i biologic, abatacept, or tofactinib. They also recommend choosing an IL-17i instead of a different OSM, an IL-12/23i biologic, abatacept, or tofacitinib, but an IL-12/23i biologic is preferred over a different OSM, abatacept, and tofacitinib.

Patients treated with a TNFi biologic who still have active disease should switch to a different TNFi biologic before switching to an IL-17i biologic, an IL-12/23i biologic, abatacept, or tofacitinib; they also recommend switching to a different TNFi biologic, with or without MTX, before adding MTX to TNFi biologic monotherapy. An IL-17i biologic is recommended over an IL-12/23i biologic, abatacept, or tofacitinib. The guidelines recommend an IL-12/23i biologic over abatacept or tofacitinib. They suggest switching to a different TNFi biologic monotherapy instead of switching to a different TNFi biologic and MTX combination therapy. It is also recommended to switch to an IL-17i biologic monotherapy versus an IL-17i biologic and MTX combination therapy, and to switch to an IL-12/23i biologic monotherapy versus an IL- IL-12/23i biologic and MTX combination therapy.

“The 2018 ACR/NPF guideline for the treatment of PsA will assist patients and their health care providers in making challenging disease management decisions,” the researchers wrote, adding, “We anticipate future updates to the guideline when new evidence is available.”

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2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

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Source: Arthritis & Rheumatology