EULAR updates management recommendations for psoriatic arthritis

The European League Against Rheumatism (EULAR) has released new guidelines on the pharmacological treatment of psoriatic arthritis (PsA). The recommendations have been published in the Annals of the Rheumatic Diseases .

Psoriatic arthritis (PsA) is a disease with heterogeneous manifestations in patients who have manifest or latent psoriasis. It comprises both musculoskeletal as well as non-musculoskeletal manifestations; the latter particularly include the skin and the nails, but also potentially the gut (inflammatory bowel disease) or the eyes (uveitis).

The recommendations have been updated twice to remain timely, responding to the rapid advances in the discovery of new compounds, effective treatment strategies and evllolving information on safety.The European League Against Rheumatism

(EULAR) developed recommendations for the

pharmacological management of PsA in 2011 and

updated them in 2015. These recommendations

had their main focus on the musculoskeletal aspects

of the disease and addressed the entire spectrum of

PsA severity since they pertained to patients with

very mild to very severe PsA.

The recommendations provide a treatment

strategy for pharmacological therapies. Non-steroidal

anti-inflammatory drugs. and local glucocorticoid

injections are proposed as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis accompanied

by factors such as dactylitis or joint damage, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended

Main recommendations include-

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.

Rephrased Treatment should be aimed at reaching the target of remission or, alternatively,minimal/low disease activity, by regular monitoring and appropriate adjustment of therapy.

2 Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms.

Rephrased In patients with psoriatic arthritis, 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.

Renumbered 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.

Modified In patients with peripheral arthritis, particularly in those with many swollen joints,structural damage in the presence of inflammation, high ESR/CRP and/or clinically relevant extra-articular manifestations, csDMARDs should be considered at an early stage, 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.

New Not applicable but partly covered in the recommendation above.

6 In patients with peripheral arthritis and an inadequate response to at least onecs DMARD, 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.

Modified and merged In patients with peripheral arthritis and an inadequate response to at least onecs DMARD, therapy with a bDMARD, usually a TNF inhibitor, should be commenced.

In patients with peripheral arthritis and an inadequate response to at least onecs DMARD, in whom TNF inhibitors are not appropriate, bDMARDs targeting IL-12/23 or IL-17 pathways may be considered.

7 In patients with peripheral arthritis and an inadequate response to at least onecs DMARD and at least one bDMARD, or when a bDMARD is not appropriate, a JAK inhibitor may be considered.

New Not applicable.

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.

Modified In patients with peripheral arthritis and an inadequate response to at least onecs DMARD, in whom bDMARDs are not appropriate, a targeted synthetic DMARD such as 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.

Modified In patients with active enthesitis and/or dactylitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor.

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.

Modified In patients with predominantly axial disease that is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor.

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†.

Modified In patients who fail to respond adequately to a bDMARD, switching to another bDMARD should be considered, including switching between TNF inhibitors.

12 In patients in sustained remission, cautious tapering of DMARDs may be considered.

The updated treatment recommendations for patients with PsA living in many different countries, under the influence of very different healthcare systems, support decision-making for the management of PsA and address the entire spectrum of the disease. An update will be needed within 2–4 years,as new data arise in PsA.

For further reference log on to:

Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020;79(6):700‐712. doi:10.1136/annrheumdis-2020-217159 .