BSR Guideline for Psoriatic Arthritis - 2022 Update Save

The British Society of Rheumatology (BSR) has published their updated 2022 recommendations for the use of biologics and targeted synthetic treatments in patients with psoriatic arthritis (PsA).  These guidelines follow initial treatment with a single conventional systemic disease-modifying anti-rheumatic drug (csDMARD), typically methotrexate typically (MTX).  They noted that up to 50% of people with PsA require biologic or targeted synthetic (b/ts)DMARD therapy. 

These guidelines were based on literature review and expert consensus and complements existing BSR guidelines on PsA; but does not include discussion of bDMARD safety, use of biologic or tsDMARDs in juvenile idiopathic arthritis, use of initial csDMARDs in PsA, drug use in pregnancy or treatment of psoriasis (skin only) patients.

Overarching generic recommendations

• Therapeutic decisions should be based on shared decision making 
• Treatment decisions should take into account disease presentations and clinical domains involved
• Cost of therapies should be considered
• PsA with an inadequate response to a b/tsDMARD should be reassessed for the correct diagnosis, adherence, pain due to other causes, drug levels and immunogenicity

Treatment recommendations by domain

Peripheral arthritis (mono-, oligo- and polyarthritis)

• Patients with active psoriatic arthritis and an inadequate response or intolerance to one csDMARD, a b/tsDMARDs should be considered
• Active peripheral psoriatic arthritis can be offered a bDMARD (TNFi, IL12/23i, IL-17i, IL-23i, CTLA4-Ig) or tsDMARD (JAKi, or PDE4i) 

PsA with enthesitis

• Active psoriatic enthesitis can be offered any bDMARD (TNFi, IL12/23i, IL-17i, IL-23i) or tsDMARD (JAKi, or PDE4i) 

PsA with dactylitis

• Active psoriatic dactylitis can be offered any bDMARD (TNFi, IL12/23i, IL-17i, IL-23i) or tsDMARD (JAKi, or PDE4i) 

PsA with axial disease

• Active psoriatic axial disease can be offered any TNFi or IL-17i or consider a JAKi 

Psoriasis

• Topical therapy can be offered with psoriasis
• For active psoriasis and/or nail psoriasis, certain therapies can be prioritized, including monoclonal TNFi, IL-17i, IL-12/23i or IL-23i
• With significant, extensive psoriasis (BSA ≥ 10 or PASI ≥ 10), IL-17i and IL23i have superior evidence of efficacy over TNFi 

Treatment strategy

• A treat-to-target strategy is recommended
• Treat-to-target strategy should aim for remission or alternatively low disease activity

Further guidance on the treatment of PsA patients with uveitis, inflammatory bowel disease, extra-articular manifestations and issues of drug switching and lifestyle choices are discussed in the full-access manuscript online.

Interested in more psoriatic arthritis news, information and updates? Visit our PsA topic page here: https://rheumnow.com/topic/psaspa