medwireNews: The American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) have issued evidence-based guidelines for the pharmacologic and nonpharmacologic treatment of active psoriatic arthritis (PsA).
These guidelines provide “a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios,” write Jasvinder Singh (University of Alabama at Birmingham, USA) and co-authors.
The expert taskforce – comprising rheumatology and dermatology specialists as well as patient representatives – carried out a systemic literature review to summarize data supporting the benefits and harms of different treatment options, and developed consensus recommendations based on this evidence.
For pharmacologic treatment, Singh and colleagues say that tumor necrosis factor (TNF) inhibitors should be used as the preferred first-line treatment ahead of oral small molecules (OSMs; including methotrexate, sulfasalazine, and leflunomide), and that OSMs or TNF inhibitors are generally recommended over interleukin (IL)-17 and IL-12/23 inhibitors.
The authors specify that patients with active PsA despite OSM treatment should switch to a biologic (TNF, IL-17, or IL-12/23 inhibitor), but that alternative OSMs can be considered for patients with contraindications to TNF inhibitors, those without evidence of severe disease, and those who prefer oral therapy. They advocate the preferential use of TNF inhibitors over abatacept, tofacitinib, IL-17 inhibitors, and IL-12/23 inhibitors in this situation.
Among patients who continue to have active PsA after treatment with a TNF inhibitor, the taskforce recommends switching to another TNF inhibitor rather than to a different biologic, except in certain situations such as the occurrence of treatment-related serious adverse events.
Singh and colleagues endorse a treat-to-target strategy, and outline patient groups for which OSMs are preferred over TNF inhibitors, such as those with concomitant diabetes or frequent serious infections.
The guideline authors note that for most clinical scenarios “there were few or no head-to-head comparison studies identified in the literature review,” and therefore the majority of recommendations “are based on low-quality evidence and are conditional.”
They add that “[s]everal ongoing trials, including a trial to compare a TNF [inhibitor] biologic combination therapy with a TNF [inhibitor] biologic monotherapy and [methotrexate] monotherapy, will inform treatment decisions.”
In terms of nonpharmacologic treatment, the recommendations state that PsA patients should “use some form or combination of exercise, physical therapy, occupational therapy, massage therapy, and acupuncture over not using these modalities as tolerated.” The team recommends low-impact exercise such as swimming over high-impact activities such as running, and says that “clinicians should encourage patients [who smoke] to stop smoking,” as well as offering cessation aids.
Similar to the pharmacologic recommendations, the experts caution that all recommendations for nonpharmacologic treatment are based on low- to very low-quality evidence, with the exception of smoking cessation.
The guidelines have been published simultaneously in Arthritis & Rheumatology, Arthritis Care & Research, and the Journal of Psoriasis and Psoriatic Arthritis.
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