Guidelines Summary
Guidelines and recommendations on psoriatic arthritis have been published by the following organizations:
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American College of Rheumatology/National Psoriasis Foundation (ACR/NPF) - updated 2018 [102]
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European League Against Rheumatism (EULAR) - updated 2015 [109]
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American Academy of Dermatology (AAD) - updated 2010 [110]
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British Society of Rheumatology (BSR) - published 2013 [111]
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Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) - updated 2015 [112]
American College of Rheumatology/National Psoriasis Foundation recommendations
The ACR/NPF guidelines have evidence-based recommendations, based on systematic literature review along with expert opinion, for both pharmacologic and nonpharmacologic treatment of active psoriatic arthritis. GRADE (Grading for Recommendation Assessment, Development and Evaluation) methodology were used for assessment. It is worth mentioning that 6% of the recommendations are strong and 96% are conditional. This highlights the importance of evaluating each case individually and engaging in a discussion with patients to assess their needs and choose optimal therapy. [102]
Pharmacologic therapy
Treatment recommendations for patients with active psoriatic arthritis who are treatment-naïve are as follows:
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Tumor necrosis factor (TNF) inhibitors are preferred over oral small molecules (OSM), interleukin-17 (IL-17) inhibitors, or IL-12/23 inhibitors
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OSM are recommended over IL-17 inhibitors or IL-12/23 inhibitors
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Methotrexate (MTX) is recommended over nonsteroidal anti-inflammatory drugs (NSAIDs)
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IL-17 inhibitors are recommended over IL-12/23 inhibitors
Treatment recommendations for patients with active psoriatic arthritis despite the use of OSM are as follows:
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Switch to a TNF inhibitor biologic over another OSM, IL-17 or IL-12/23 inhibitors, abatacept, or tofacitinib
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Switch to an IL-17 inhibitor biologic over another OSM, IL-12/23 inhibitor, abatacept, or tofacitinib
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Switch to an IL-12/23 inhibitor biologic over another OSM, abatacept, or tofacitinib
Treatment recommendations for patients with active psoriatic arthritis despite TNF inhibitor monotherapy are as follows:
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Switch to a different TNF inhibitor or add methotrexate over IL-17 or IL-12/23 inhibitors, abatacept, or tofacitinib
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Switch to an IL-17 inhibitor biologic over IL-12/23 inhibitor, abatacept, or tofacitinib
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Switch to an IL-12/23 inhibitor biologic over another OSM, abatacept, or tofacitinib
Treatment recommendations for patients with active psoriatic arthritis despite TNF inhibitor plus MTX combination therapy are as follows:
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Switch to a different TNF inhibitor + methotrexate over TNF inhibitor monotherapy
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Switch to IL1-7 inhibitor biologic monotherapy over IL17 inhibitor + MTX
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Switch to IL-12/23 inhibitor inhibitor biologic monotherapy over IL-12/23 inhibitor + MTX
Treatment recommendations for patients with active psoriatic arthritis despite IL-17 inhibitor biologic are as follows:
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Switch to a TNF inhibitor biologic over IL-12/23 inhibitor biologic, a different IL-17 inhibitor, or adding MTX
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Switch to an IL-12/23 inhibitotr biologic over a different IL-17 inhibitor or adding MTX
Treatment recommendations for patients with active psoriatic arthritis despite IL-17 inhibitor biologic are as follows:
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Switch to a TNF inhibitor biologic over IL-17 inhibitor biologic or adding MTX
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Switch to an IL-17 inhibitor biologic over adding MTX
Other considerations are as follows:
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If the patient prefers oral medication, consider an OSM or tofacitinib
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If the patient has inflammatory bowel disease, consider an IL-12/23 inhibitor or tofacitinib
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If the patient prefers less frequent dosing, consider an IL-12/23 inhibitor
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If the patient has recurrent or serious infections, avoid TNF inhibitors and consider abatacept
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If the patient has recurrent Candida infections, consider tofacitinib
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If the patient has diabetes, start an OSM other than MTX, or IL-12/23i over a TNF inhibitor
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Uveitis responds well to MTX
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Consider OSM if the psoriatic arthritis is not severe and psoriasis is absent
Nonpharmacologic therapy
Recommendations include the following:
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Using physical therapy, exercise, massage therapy, acupuncture is recommended over not using it.
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Smoking cessation is advised.
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Weight loss for patients with high body mass index (BMI) is recommended.
EULAR recommendations
Based on evidence from systematic literature reviews and expert opinion, EULAR developed the 2012 guidelines, with a 2015 update. The guidelines are centered on five overarching principles, 10 specific recommendations, and a treatment algorithm. Specific treatment recommendations are outlined for peripheral arthritis, axial disease, dactylitis, and enthesitis, along with a consideration of comorbidities in the treatment approach. The 10 recommendations are as follows [109] :
- Treatment should be aimed at reaching the target of remission or, alternatively, LDA or Mlow or minimal disease activity, by regular monitoring and appropriate adjustment of therapy
- NSAIDs may be used to relieve musculoskeletal signs.
- In patients with peripheral arthritis, particularly those with many swollen joints, structural damage, high ESR/CRP, and/or clinically relevant extra-articular manifestations, conventional synthetic DMARDs should be considered, with MTX preferred in those with relevant skin involvement.
- Local injections of glucocorticoids should be considered as adjunctive therapy; systemic glucocorticoids may be used with caution at the lowest effective dose.
- In patients with peripheral arthritis and an inadequate response to at least one conventional synthetic DMARD, therapy with a biologic DMARD, usually a TNF inhibitor, should be commenced.
- In patients with peripheral arthritis and an inadequate response to ≥1 conventional synthetic DMARD in whom TNF inhibitors are not appropriate, biologic DMARDs targeting IL-2/23 or IL-17 pathways may be considered.
- In patients with peripheral arthritis and an inadequate response to at least one conventional synthetic DMARD, in whom biologic DMARDs are not appropriate, a targeted synthetic DMARD such as a PDE4-inhibitor may be considered.
- In patients with active enthesitis and/or dactylitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a biologic DMARD should be considered, which according to current practice is a TNF inhibitor.
- In patients with predominantly axial disease that is active and has insufficient response to NSAIDs, therapy with a biologic DMARD should be considered, which according to current practice is a TNF inhibitor.
- In patients who fail to respond adequately to a biologic DMARD, switching to another bDMARD should be considered, including switching between TNF inhibitors.
EULAR has also published recommendations on the following, which are all relevant for patients with psoriatic arthritis:
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Vaccination in adult patients with autoimmune inflammatory rheumatic disease (2019) [113]
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Cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders (2016) [114]
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Use of imaging and management of spondyloarthritis in clinical practice (2015) [115]
American Academy of Dermatology recommendations
General recommendations on psoriatic arthritis from the AAD are as follows [110] :
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Upon diagnosis of psoriatic arthritis, patients should be treated and/or referred to a rheumatologist.
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MTX or TNF blockade or the combination of these therapies is considered first-line treatment for patients with moderate to severely active psoriatic arthritis.
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Not all patients with psoriatic arthritis require treatment with MTX or TNF blockade. Patients with mild psoriatic arthritis can be successfully treated with NSAIDs or intraarticular injections of corticosteroids.
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The choice of which TNF agent to utilize is an individual one, with the degree and severity of cutaneous involvement an important consideration.
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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:
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Anti-TNF agents are contraindicated in patients with active, serious infection.s
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Tuberculosis testing (PPD) should be performed on all patients who will be treated with TNF inhibitors, given the risk of tuberculosis reactivation.
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Do not use with live vaccines; biologically inactive or recombinant vaccines may be considered, although the immune response to these vaccines could be compromised.
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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 18 to 36, which strongly suggests that TNF inhibitors should not be used in first-degree relatives of patients with MS.
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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.
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In the appropriate clinical setting, patients should be screened for hepatitis B virus (HBV) infection.
British Society of Rheumatology recommendations
The BSR issued guidelines for the treatment of adult psoriatic arthritis with biologic agents (particularly anti-TNF therapy). [111, 116] The BSR recommends considering anti-TNF treatment in patients with any of the following [111] :
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Active peripheral arthritis refractory to at least 2 conventional DMARDs
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Peripheral disease refractory to 1 DMARD plus the presence of adverse prognostic factors
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Severe persistent oligoarthritis that is affecting well-being and refractory to at least 2 DMARDs and intra-articular therapy
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Axial disease
The BSR recommendations on response assessment include the following [111] :
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Use the psoriatic arthritis response criteria as the clinical response criteria for peripheral disease.
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Use the psoriasis area severity index (PASI) score for significant skin psoriasis.<
Safety recommendations include the following [111] :
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Do not start or continue anti-TNF therapy in patients with serious active infection; use caution in those at high risk of infection.
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Screen all patients for infection with mycobacteria, human immunodeficiency virus (HIV), HBV, and hepatitis C virus(HCV) before starting anti-TNF therapy.
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Consider prophylactic vaccination for tuberculosis and HBV in high-risk patients before initiating anti-TNF therapy.
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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.
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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.
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Regularly screen for skin cancers in patients who are receiving anti-TNF therapy and who have a history of current or previous malignancy.
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Discontinue anti-TNF therapy prior to pregnancy; restart anti-TNF treatment following the end of lactation, or delivery if the mother is not breastfeeding.
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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.
Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations for the spectrum of manifestations of psoriatic arthritis were updated in 2015. Among the overarching principles for care, the GPAPPA set the goals of therapy as follows [112] :
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To achieve the lowest possible level of disease activity in all domains of disease
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To optimize functional status, improve quality of life and well‐being, and prevent structural damage to the greatest extent possible
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To avoid or minimize complications, both from untreated active disease and from therapy
The following therapies were strongly recommended [112] :
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For peripheral arthritis in DMARD-naive patients: MTX, sulfasalazine, leflunomide, and a TNF inhibitor
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For peripheral arthritis with inadequate response to DMARDs: TNF inhibitor, IL‐12/23 inhibitor, phosphodiesterase 4 (PDE‐4) inhibitor
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For peripheral arthritis with inadequate response to biologic treatment: TNF inhibitor
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For axial psoriatic arthritis in biologic‐naive patients: NSAIDs, physiotherapy, simple analgesia, TNF inhibitor
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For axial psoriatic arthritis with inadequate response to biologic treatment: physiotherapy, simple analgesia
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For plaque psoriasis: topical therapies, phototherapy, DMARDs, TNF inhibitor, IL‐12/23 inhibitor, IL‐17 inhibitor, PDE‐4 inhibitor
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For nail psoriasis: TNF inhibitor, IL‐12/23 inhibitor
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Severe fixed flexion deformity of the interphalangeal joint.
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Comparison between sites of involvements in both hands and feet in psoriatic arthritis and rheumatoid arthritis.
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Psoriatic arthritis involving the distal phalangeal joint.
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Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis.
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Psoriatic arthritis involving the distal phalangeal joint.
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Psoriatic arthritis involving the distal phalangeal joint.
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Asymmetrical arthritis pattern of psoriatic arthritis (fixed flexion deformity).
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Arthritis mutilans, a typically psoriatic pattern of arthritis, which is associated with a characteristic "pencil-in-cup" radiographic appearance of digits.
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Psoriatic arthritis involving the distal phalangeal joint.
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Arthritis mutilans (ie, "pencil-in-cup" deformities).
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Severe psoriatic arthritis showing involvement of the distal interphalangeal joints, distal flexion deformity, and telescoping of the left third, fourth, and fifth digits due to destruction of joint tissue.
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Psoriatic arthritis showing nail changes, distal interphalangeal joint swelling, and sausage digits.
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Left, typical appearance of psoriasis, with silvery scaling on a sharply marginated and reddened area of skin overlying the shin. Right, thimblelike pitting of the nail plate in a 56-year-old woman who had suffered from psoriasis for the previous 23 years. Nail pitting, transverse depressions, and subungual hyperkeratosis often occur in association with psoriatic disease of the distal interphalangeal joint. Courtesy of Ali Nawaz Khan, MBBS.
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Lateral radiograph of the cervical spine shows syndesmophytes at the C2-3 and C6-7 levels, with zygapophyseal joint fusion. Courtesy of Bruce M. Rothschild, MD.
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A 37-year-old man presents with a 1-year history of an erythematous and intensely pruritic rash at the bilateral soles of feet. He has mild dryness and fissuring at his hands, but no overlying scale, intense erythema, or itching like that at his feet. Diagnosis: Psoriatic arthritis (PsA), with palmoplantar pustulosis variant of psoriasis. Courtesy of Jason Kolfenbach, MD, and Kevin Deane, MD, Division of Rheumatology, University of Colorado Denver School of Medicine.
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Patient with psoriatic arthritis involving the joints and skin displays features of arthritis mutilans with distal interphalangeal joint destruction causing a deformity and compromise to function.
Tables
Laboratory Studies |
Psoriatic Arthritis |
Rheumatoid Arthritis |
Erythrocyte sedimentation rate |
Elevated (< 100) |
Elevated (< 100) |
Rheumatoid factor |
Negative |
Positive (85% of patients) |
Antinuclear antibody |
Negative |
Positive (30% of patients) |
C-reactive protein |
Elevated |
Elevated |
Synovium |
WBC count 5000-15,000/µL, >50% polymorphonuclear leukocytes |
WBC count 2000/µL |
