Psoriatic Arthritis Guidelines

Updated: Oct 25, 2019
  • Author: Anwar Al Hammadi, MD, FRCPC; Chief Editor: Herbert S Diamond, MD  more...
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Guidelines

Guidelines Summary

Guidelines on psoriatic arthritis have been published by the following organizations:

  • European League Against Rheumatism (EULAR) [79]
  • British Society of Rheumatology (BSR) [80]
  • American Academy of Dermatology (AAD) [81]
  • American College of Rheumatology/National Psoriasis Foundation [82]

EULAR recommendations

Based on evidence from systematic literature reviews and expert opinion, the EULAR developed 10 treatment recommendations, 5 overarching principles, and a research agenda for psoriatic arthritis. The recommendations are as follows [79] :

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can be given to relieve musculoskeletal signs and symptoms

  • Treatment with disease-modifying antirheumatic drugs (DMARDs)—eg, methotrexate, sulfasalazine, and leflunomide—should be considered at an early stage for patients with active disease

  • If a patient with active psoriatic arthritis also has clinically relevant psoriasis, preference should be given to treatment with methotrexate or other DMARDs that are also effective against psoriasis

  • Adjunctive treatment with local corticosteroid injections should be considered; cautious use of systemic steroids, if administered at the lowest effective dose, can also be considered

  • If active psoriatic arthritis fails to adequately respond to 1 or more synthetic, DMARDs (eg, methotrexate), tumor necrosis factor (TNF)–inhibitor therapy should be employed

  • TNF-inhibitor therapy should also be considered if active enthesitis and/or dactylitis does not show sufficient response to NSAIDs or local steroid injections

  • TNF-inhibitor therapy should be considered if a patient has active, predominantly axial disease that does not respond sufficiently to NSAIDs

  • Exceptional use of TNF-inhibitor therapy may be considered if a very active patient is DMARD-treatment naïve

  • If a TNF inhibitor produces an inadequate response, consideration should be given to replacing it with another TNF inhibitor

  • If adjustments are made in a patient’s therapy, then comorbidities, safety concerns, and other considerations beyond the psoriatic arthritis itself should be factored into the change

British Society of Rheumatology recommendations

The BSR issued guidelines for the treatment of adult psoriatic arthritis with biologic agents (particularly anti-TNF therapy). [80, 83]  The BSR recommends considering anti-TNF treatment in patients with any of the following [80] :

  • Active peripheral arthritis refractory to at least 2 conventional DMARDs

  • Peripheral disease refractory to 1 DMARD plus the presence of adverse prognostic factors

  • Severe persistent oligoarthritis that is affecting well-being and refractory to at least 2 DMARDs and intra-articular therapy

  • Axial disease

The BSR recommendations on response assessment include the following [80] :

  • Use the psoriatic arthritis response criteria as the clinical response criteria for peripheral disease

  • Use the psoriasis area severity index score for significant skin psoriasis

Safety recommendations include the following [80] :

  • Do not start or continue anti-TNF therapy in patients with serious active infection; use caution in those at high risk of infection

  • Screen all patients for infection with mycobacteria, human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) before starting anti-TNF therapy

  • Consider prophylactic vaccination for tuberculosis and HBV in high-risk patients before initiating anti-TNF therapy

  • In patients with HIV, HBV, or HCV, initiate anti-TNF therapy only in those with well-controlled disease and appropriate monitoring; appropriate antiviral therapy for patients with HBV is also important

  • Avoid anti-TNF treatment in patients with a current or previous history of malignancy, unless there is a high likelihood of cure or the malignancy was diagnosed and treated more than 10 years ago

  • Regularly screen for skin cancers in patients who are receiving anti-TNF therapy and who have a history of current or previous malignancy

  • Discontinue anti-TNF therapy prior to pregnancy; restart anti-TNF treatment following the end of lactation or delivery if the mother is not breastfeeding

  • Consider an alternative anti-TNF agent in patients whose condition is refractory to a first anti-TNF agent; assess the treatment response as for the first agent

American Academy of Dermatology recommendations

General recommendations on psoriatic arthritis from the AAD are as follows [81] :

  • Upon diagnosis of psoriatic arthritis, patients should be treated and/or referred to a rheumatologist.
  • Methotrexate or TNF blockade or the combination of these therapies is considered first-line treatment for patients with moderate to severely active psoriatic arthritis.  
  • Not all patients with psoriatic arthritis require treatment with methotrexate or TNF blockade. Patients with mild psoriatic arthritis can be successfully treated with NSAIDs or intraarticular injections of corticosteroids.
  • The choice of which TNF agent to utilize is an individual one, with the degree and severity of cutaneous involvement an important consideration.
  • Common safety concerns need to be considered when using TNF inhibitors to treat patients who have psoriatic arthritis.

General recommendations on the use of TNF inhibitors in psoriatic arthrits are as follows:

  • Anti-TNF agents are contraindicated in patients with active, serious infections
  • Tuberculosis testing (PPD) should be performed on all patients who will be treated with TNF inhibitors, given the risk of tuberculosis reactivation.
  • Do not use with live vaccines; biologically inactive or recombinant vaccines may be considered, although the immune response of these vaccines could be compromised
  • Because there is an association between anti-TNF therapy and demyelinating diseases (ie, multiple sclerosis [MS]), TNF inhibitors should not be used in patients with MS or other demyelinating diseases. First-degree relatives of patients with MS have an increased risk of developing MS, with a sibling relative risk of between 18 and 36, which strongly suggests that TNF inhibitors should not be used in first-degree relatives of patients with MS
  • Caution should be used when considering TNF inhibitor use in patients with chronic heart failure (CHF); patients with New York Heart Association (NYHA) class III or IV CHF should avoid all use of TNF inhibitors, and patients with NYHA class I or II CHF should undergo echocardiogram testing, and if their ejection fraction is < 50%, then TNF inhibitor treatment should potentially be avoided.
  • In the appropriate clinical setting, patients should be screened for HBV infection.

American College of Rheumatology/National Psoriasis Foundation recommendations

This collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) covers the management of active psoriatic arthritis in patients who are treatment-naive and in those who continue to have active psoriatic arthritis despite treatment. [82]

TNF inhibitors

Etanercept recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 50 mg; self-administered SC injection twice weekly for 12 consecutive weeks

  • Recommended maintenance dose of 50 mg once weekly; 50 mg twice weekly is more efficacious than once weekly and may be required for better disease control in some patients

  • Recommended as monotherapy option in adults with moderate-to-severe plaque psoriasis affecting the scalp or nails

  • Can be recommended as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • Recommended combination treatment option with methotrexate for moderate-to-severe plaque psoriasis in adults

  • May be combined with acitretin, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Infliximab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose is an infusion of 5 mg/kg administered at week 0, week 2, and week 6; thereafter, administered every 8 weeks

  • Recommended to be administered at more frequent intervals (less than q8wk and as frequently as q4wk during maintenance phase) and/or at a higher dose (up to 10 mg/kg) for better disease control in some adults

  • Recommended as monotherapy option for moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp in adults

  • Can be recommended as monotherapy option in adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis; it also inhibits radiographically detected joint damage in psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, or apremilast for moderate-to-severe plaque psoriasis in adults

Adalimumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 80 mg taken as two self-administered SC 40-mg injections, followed by a 40-mg self-administered SC injection 1 week later, followed by 40-mg self-administered SC injections every 2 weeks thereafter

  • Maintenance dose of 40 mg/wk recommended for better disease control in some patients

  • Recommended as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (palmoplantar psoriasis), nails, or scalp

  • Can be recommended as monotherapy option for adults patients with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Certolizumab has been approved by the US Food and Drug Administration (FDA) for the treatment of plaque psoriasis, psoriatic arthritis, Crohn disease, ankylosing spondylitis, and rheumatoid arthritis. Approved dosing for moderate-to-severe psoriasis is 400 mg (two 200-mg SC injections) every other week. It is likely to possess class characteristics similar to those of other TNF-alpha inhibitors.

Interleukin-12/23 Inhibitors

Ustekinumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting doses: (1) patients weighing 100 kg or less, 45 mg SC initially and 4 weeks later, followed by 45 mg administered SC every 12 weeks; (2) patients weighing more than 100 kg, 90 mg administered SC initially and 4 weeks later, followed by 90 mg administered SC every 12 weeks

  • Recommended alternate dosages are higher doses (90 mg instead of 45 mg in patients weighing ≥100 kg) or with greater frequency (eg, every 8 wk in maintenance phase) if response to standard dosing is inadequate

  • Can be used as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp

  • Can be used as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis; evidence is limited for use in inverse and guttate psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Interleukin-17 Inhibitors

Secukinumab recommendations are as follows:

  • Monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 300 mg by self-administered SC injection at week 0, week 1, week 2, week 3, and week 4, followed by 300 mg every 4 weeks

  • Recommended maintenance dose of 300 mg every 4 weeks

  • Recommended dose of 300 mg is more effective than 150 mg

  • Can be recommended as monotherapy in adults with moderate-to-severe plaque psoriasis affecting the head and neck (including the scalp) or nails

  • Recommended as monotherapy option in adults with moderate-to-severe palmoplantar plaque psoriasis

  • Can be recommended as monotherapy option in adults with moderate-to-severe palmoplantar pustulosis

  • Can be used as monotherapy in adults with erythrodermic psoriasis

  • May be used as monotherapy in adults with plaque psoriasis when associated with psoriatic arthritis

Ixekizumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 160 mg by self-administered SC injection, followed by 80 mg at week 2, week 4, week 6, week 8, week 10, and week 12

  • Recommended maintenance dose of 80 mg every 4 weeks

  • Can be recommended as monotherapy option in adults with moderate-to-severe plaque psoriasis affecting the scalp or nails

  • Can be recommended as monotherapy option in adults with erythrodermic psoriasis or generalized pustular psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis when associated with psoriatic arthritis

Brodalumab recommendations are as follows:

  • Recommended as monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Can be used as monotherapy option in adults with generalized pustular psoriasis

  • Recommended dose of 210 mg by self-administered SC injection at week 0, week 1, and week 2, followed by 210 mg every 2 weeks

Interleukin-23 Inhibitors

Guselkumab recommendations are as follows:

  • Recommended as monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended dose of 100 mg by self-administered SC injection at week 0 and week 4, followed by every 8 weeks thereafter

  • Recommended as monotherapy option in adults with scalp, nail, or plaque-type palmoplantar psoriasis

Tildrakizumab recommendations are as follows:

  • Recommended as monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Recommended dose of 100 mg given in office by physician-administered SC injection at week 0 and week 4, followed by every 12 weeks thereafter

Risankizumab is not approved by the FDA, but it can be used as monotherapy in adults with moderate-to-severe plaque psoriasis. When approved, the dose will likely be 150 mg given by self-administered subcutaneous injections at week 0 and week 4, followed by every 12 weeks.