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Medicine Matters rheumatology

INTERVIEWER: Hello, and welcome to this Medicine Matters podcast. Recently, the American College of Rheumatology and the National Psoriasis Foundation released their first evidence based guidelines for the management of psoriatic arthritis. In the first of a two part series on the new guidelines, we spoke with Prof Dafna Gladman from the University of Toronto, Canada, Prof Philip Mease from the University of Washington, Seattle, USA, and Prof Oliver FitzGerald from University College Dublin, Ireland, about how the new guidelines were developed, and the key differences between the new ACR-NPF guidelines and the pre-existing EULAR and GRAPPA guidelines.


INTERVIEWER:  Firstly, Dafna, as a member of the core leadership team, could you tell us about the approach taken when developing the ACR-NPF guidelines?


DAFNA: So this guideline was based on the assessment of the literature according to the GRADE system. There was a literature review committee which consisted of an independent group that was not made out of members of the American College of Rheumatology, and in fact did not have rheumatologists specifically on that panel. They reviewed the literature, and developed the analysis which was based on a network meta-analysis. Aside from the literature review committee, there was a core committee, which I was a member of, that oversaw the whole process, developed PICO questions, and those questions were then accepted by an expert review committee, as well as a voting committee. The guideline was then submitted to the ACR board, the Arthritis and Rheumatology journal, and underwent a review, a scientific review, before it finally came out.


PHILIP: Dafna, could you share with us a bit more about the PICO questions so that we can understand more about the outcomes of the guideline process?


DAFNA:  So the P stands for problem, patient, population, the I is intervention, the C is comparison intervention, and the O is the outcome. So in our case the P of course was patients with psoriatic arthritis, the interventions were the various drugs that we were looking at. And the comparison was done looking at the individual papers, and it had to be a network meta-analysis because we did not have any direct comparisons between the various modalities. And of course the outcome was ACR20, and the HAQ disability index. As well as safety indications.


INTERVIEWER: Philip, you were on the voting panel for the new guidelines - how did this process differ from that used in the GRAPPA guidelines?


PHILIP: In the case of the ACR-NPF guideline, it was a combined effort between the American College of Rheumatology and the National Psoriasis Foundation in America. And both of these organizations represent psoriatic arthritis constituencies, both clinician investigators, clinicians in general, as well as patients.  The GRAPPA guidelines were convened by the organization known as Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. And this is an international organization that's comprised of key investigators, clinicians, regulators, patient organizations etc. that are interested in both psoriasis and psoriatic arthritis. There are approximately 1000 members of the organization at this time representing both dermatology and rheumatology, so it's fairly unique as an organization in that it crosses across two different disciplines.


INTERVIEWER: Oliver, you were involved in the EULAR and GRAPPA guidelines, what are your thoughts on the processes involved?


OLIVER: EULAR guidelines were developed by the EULAR organization and there was a committee set up, made up of predominantly rheumatologists, there was one dermatologist on the committee. But the focus was to look at recommendations for treatment in psoriatic arthritis, and not psoriasis, hence the small number of dermatologists that were involved. I guess in that sense it's more like the ACR-NPF recommendations than the GRAPPA recommendations which of course included dermatologists and included recommendations for treatment of psoriasis.


INTERVIEWER: How do you think the clinical focus differs for each of the guidelines?


PHILIP: The GRAPPA group split itself into different committees that reviewed the evidence for each of the key clinical domains of psoriatic arthritis, and that includes peripheral arthritis, skin disease, nail disease, spondylitis, enthesitis, and dactylitis.  And so each committee looked carefully at all of the treatment trials for the various medications and then analyzed whether or not there was demonstrated effectiveness for each of those domains.


DAFNA: The ACR-NPF is based on active psoriatic arthritis, which includes all of the domains, but not specifically referring to an individual domain, although there were specific recommendations for enthesitis, spinal disease.


OLIVER: The EULAR focus was certainly more narrow, I think than either of the two guidelines, the focus was on treatment of psoriatic arthritis. It didn't look at other issues that, for example, the ACR-NPF guidelines looked at. They looked at the influence of comorbidities, treat-to-target, they looked at non-pharmacological treatments. So those were not included at all in the EULAR guidelines, so it's purely focused on psoriatic arthritis.The ACR-NPF guidelines didn't break it down into the various components of psoriatic arthritis either.


INTERVIEWER: Finally, are there differences in the treatment recommendations between the guidelines?


PHILIP: The way in which the GRAPPA group does its work is that they analyse the data for all classes of medications and if the medication appears to have an effectiveness in a particular clinical domain of psoriatic arthritis, then all are presented as a group that are effective. Where the ACR and NPF provides a bit more guidance by having to choose one class over another. So I would say then, that, other than the fact that there's a bit broader choice given to clinicians in the GRAPPA guidelines, as compared to the ACR guidelines, the outcomes were actually fairly similar. And a key example being that in the ACR-NPF guidelines a fairly striking recommendation was to recommend starting with a TNF inhibitor before methotrexate for the majority of patients, unless there is a specific contraindication to using a TNF inhibitor. And the GRAPPA guideline, they're both offered as a first option. TNF inhibitors and methotrexate both; either could be chosen. Also for that matter, apremilast.


OLIVER: The EULAR recommendations I think at this point are the oldest of the three. And they obviously would not have included some agents that have become available since 2015 such as JAK inhibitors and largely the IL-17 inhibitors were only beginning to come out around that time, so there's limited information available about that. One of the key findings that's different is the recommendation that for a patient with active psoriatic arthritis, that methotrexate should be considered as a first line treatment, and that's certainly different to what is recommended by the NPF-ACR guidelines.


INTERVIEWER: Thank you very much to Dafna, Philip and Oliver for sharing their thoughts with us on this topic Join us next time for the second part of this podcast, where we will be discussing the implications of the new ACR-NPF guidelines on clinical practice, their limitations, and key research trials in the management of psoriatic arthritis.