2021 GRAPPA Recommendations - Looking Back, Looking Forward Save

With the recent publication of the third iteration of the GRAPPA Psoriatic Arthritis (PsA) treatment recommendations (1), it seems to be an auspicious time to reflect on some key considerations that arose during the development of the recommendations, as well as to look towards what the future may hold.

As the hard work of accruing, reviewing, and excerpting data from the relevant literature was taking place, it became clear that there were several topics of great relevance to patients and providers that did not fit strictly within any single domain of PsA nor individual therapeutic agents. Thus, new in this 3rd version of the recommendations, position statements were added (based on the best available evidence, and after thorough discussion with all stakeholders) on the topics of biosimilars and tapering of therapies.

In common, these topics are relevant across multiple autoimmune systemic inflammatory diseases. Similarly, there are other topics of enormous relevance to patients with various rheumatic diseases that have been addressed by other groups. A prominent example is reproductive health. Rather than try to re-create this specifically for PsA, we referenced recent definitive work done by other groups (in this case, the ACR reproductive health guidelines).

The number of well designed research studies on PsA in the medical literature has increased exponentially since the last version of the guidelines. Also, while all were very excited to see novel study designs, such as head-to-head studies of agents with distinct mechanisms of action, there was still felt to be an unmet need as regards further research.

A common area ripe for further study would fit under the rubric of “personalized medicine”. Indeed, as in many areas of medicine, and certainly rheumatology, the key question in PsA is “what is the best drug for the next individual patient”. With numerous therapeutic choices available, it is indeed challenging to know how best to optimally sequence treatments.

Overall, the extent of involvement of activity across the various domains of PsA, and their impact on the patient, can help focus treatment choice. In some situations, safety considerations can help guide the choice of treatments; this was reviewed in detail in the comorbidities and associated diseases sections, and in the brief case scenarios.

Although in the clinic, factors such as cost and access are very important in therapeutic choices, these are not strictly evidence based, and are not consistent in different parts of the world, so they are not covered in these recommendations. Further research that would help guide ‘personalized medicine’ for PsA is eagerly awaited.

An ongoing challenge for any set of treatment recommendations, in an area as dynamic as PsA, is timeliness. Literature searches need to have a fixed end time, yet progress continues apace and new data is continuously being generated. As these recommendations were being generated, there were indeed new developments in PsA. In some cases, these can be considered ‘covered’ insofar as new agents with the same mechanism of action as older agents could be considered within the class, until such time as differential efficacy or safety of individual agents could be shown definitively. There will no doubt be exciting new developments in PsA that will need to be covered in the next version of the recommendations.

One area that is being watched closely is the possibility of combination therapy. While previous attempts have yielded disappointing results, there are a number of ongoing studies that may show promise. So the process for the next set of recommendations has already begun!

(1).  Coates LC, Soriano E, Corp N, Bertheussen H, Callis Duffin K, Campanholo CB, Chau J, Eder L, Fernandez-Avila D, FitzGerald O, Garg A, Gladman DD, Goel N, Helliwell PS, Husni ME, Jadon DR, Katz A, Laheru D, Latella J, Leung Y-Y, Lindsay C, Lubrano E, Mazzuoccolo LD, Mease PJ, O’Sullivan D, Ogdie A, Olsder W, Palominos PE, Schick L, Steinkoenig I, de Wit M, van der Windt DA, Kavanaugh A.  Group for research and assement of psoriasis and psoriatic arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021 Nat Rev Rheumatol. .