New ACR/NPF Guidelines for Management of Psoriatic Arthritis Save

The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) have released a joint treatment guideline for psoriatic arthritis (PsA) that provides evidence-based pharmacologic and non-pharmacologic recommendations and includes recommendations on other management issues including vaccinations, psoriatic spondylitis, enthesitis, and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections.

PsA is a chronic inflammatory musculoskeletal disease most commonly found in patients with psoriasis, a skin disease that causes red, scaly patches to appear on the skin. According to the NPF, more than 8 million Americans suffer from psoriasis, and it is estimated that 30 percent of them may develop PsA.

These guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Due to limited data in some areas, the quality of evidence was often graded low or very low. This led to nearly all recommendations being conditional. A voting panel of rheumatologists, dermatologists, health professionals, and patients achieved consensus on the direction and the strength of the recommendations.

Some key recommendations from the guideline include: `

• A conditional recommendation to use treat-to-target approach for all patients with active PsA.
• Treatment naive, active PsA -  conditional recommendation to use tumor necrosis factor inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA (over DMARDs/OSM).
• Oral Small Molecule (OSM) drugs (methotrexate, sulfasalazine, cyclosporine, leflunomide, apremilast) may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis or in those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment (congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease).
• For treatment-naive patients with active PsA, the use of TNFi biologic or OSM is recommended over an interleukin-17.
• inhibitor (IL-17i) or IL-12/23i biologic. An IL-17i or IL-12/23i biologi may be used instead of TNFi biologics in patients with severe psoriasis or contraindications to TNFi biologics.
• In patients with active PsA despite OSM therapy, switching to a TNFi, an IL-17i, or an IL-12/23i biologic is recommended over switching to a different OSM A different OSM may be used rather than a TNFi, IL-17i, or IL-12/23i in patients who prefer an oral medication or those without evidence of severe PsA or severe psoriasis. 
• In patients with active PsA despite TNFi treatment, switching to a different TNFi biologic monotherapy is recommended over switching to IL-12/23i biologic, an IL-17i biologic, abatacept, or tofacitinib monotherapy or adding MTX to the current TNFi biologic;  An IL-12/23i biologic, IL-17i biologic, abatacept, or tofacitinib may be used instead of a different TNFi biologic monotherapy in the case of a primary TNFi biologic failure or a serious adverse event due to the TNFi biologic.
• An IL-17i or IL-12/23i biologic may be used instead of a different TNFi biologic, particularly in the presence of severe psoriasis. Abatacept may be used instead of a TNFi biologic in patients with recurrent or serious infections in the absence of severe psoriasis.
• In treatment-naive PsA patients with predominant enthesitis, a TNFi biologic is recommended over an OSM as a first-line option. Apremilast may be used instead of a TNFi biologic if the patient prefers an oral therapy or has contraindications to TNFi.
• A strong recommendation for smoking avoidance/cessation. 

The use of TNFi biologics as a first-line therapy was one of many recommendations included to help providers and patients decide between the various pharmacologic options currently available. While current GRAPPA recommendations address the use of TNFi biologics in treatment-naïve patients, this is the first guideline that specifically recommends first trying them over oral small molecule (OSM) drugs (methotrexate, sulfasalazine, cyclosporine, leflunomide, apremilast).  These guidelines were formulated before the recently presented "SEAM" study showing the equivalent efficacy of MTX and etanercept in patients with active PsA. 

Tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs.

The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics; the benefits of smoking cessation; and the well-established link of smoking with mortality, cancers and heart and lung diseases in the general population.

Surprisingly little mention was made of obesity management and weight loss in treating active PsA.