EULAR Updated 2019 Recommendations for Psoriatic Arthritis Management Save

In June 2020, we failed to report on the ARD publication updating the 2019 update the European League Against Rheumatism (EULAR) recommendations for the pharmacological treatment of psoriatic arthritis (PsA) - these are presented below.

This guideline committee included 28 international taskforce members who met in 2019 and put forth 6 overarching principles and 12 recommendations based on the most recent review of the literature and expert discussion.

The overarching principles address the nature of PsA and diversity of both musculoskeletal and non-musculoskeletal manifestations; the need for collaborative management and shared decision-making is highlighted. The recommendations provide a treatment strategy for pharmacological therapies.

Overarching Principles

• Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment
• Treatment of psoriatic arthritis patients should aim at the best care and must be based on a shared decision between the patient and the rheumatologist, considering efficacy, safety and costs
• Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with psoriatic arthritis; in the presence of clinically significant skin involvement, a rheumatologist and a dermatologist should collaborate in diagnosis and management
• The primary goal of treating patients with psoriatic arthritis is to maximise health-related quality of life, through control of symptoms, prevention of structural damage, normalisation of function and social participation; abrogation of inflammation is an important component to achieve these goals.
• In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly.
• When managing patients with psoriatic arthritis, non-musculoskeletal manifestations (skin, eye and gastrointestinal tract) should be taken into account; comorbidities such as metabolic syndrome, cardiovascular disease or depression should also be considered.

Recommendations

1. Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy
2. Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms
3. Local injections of glucocorticoids should be considered as adjunctive therapy in psoriatic arthritis; systemic glucocorticoids may be used with caution at the lowest effective dose
4. In patients with polyarthritis, a csDMARD should be initiated rapidly, with methotrexate preferred in those with relevant skin involvement
5. In patients with monoarthritis or oligoarthritis, particularly with poor prognostic factors such as structural damage, high erythrocyte sedimentation rate/C reactive protein, dactylitis or nail involvement, a csDMARD should be considered
6. In patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD should be commenced; when there is relevant skin involvement, an IL-17 inhibitor or IL-12/23 inhibitor may be preferred
7. In patients with peripheral arthritis and an inadequate response to at least one csDMARD and at least one bDMARD, or when a bDMARD is not appropriate, a JAK inhibitor may be considered
8. In patients with mild disease* and an inadequate response to at least one csDMARD†, in whom neither a bDMARD nor a JAK inhibitor is appropriate*, a PDE4 inhibitor may be considered
9. In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered
10. In patients with predominantly axial disease which is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor; when there is relevant skin involvement, IL-17 inhibitor may be preferred
11. In patients who fail to respond adequately to, or are intolerant of a bDMARD, switching to another bDMARD or tsDMARD should be considered*, including one switch within a class
12. In patients in sustained remission, cautious tapering of DMARDs may be considered.

ement of PsA, based on a combination of evidence and expert opinion