Updated recommendations for the treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is an autoimmune inflammatory disease. It presents with both joint-related and non-articular symptoms and manifestations, which can vary between individuals. PsA is often associated with psoriasis, which affects the skin and nails, but can also be associated with inflammation of the intestines and eyes. PsA is also associated with cardiovascular, psychological and metabolic comorbidities, which have a significant impact on quality of life.

However, in recent years, treatment options for this disease have increased significantly, with both pharmacological and non-pharmacological treatments now available.

The EULAR recommendations for the pharmacological treatment of PsA were first written in 2012 and updated in 2015 and 2019. Since then, drugs with new mechanisms of action have become available, and there is a wealth of new long-term data on existing drugs.

The updated guidelines include seven general principles, three of which are unchanged from the last publication and three of which have been reformulated. One new principle states that treatment choices should take into account safety considerations across individual mechanisms of action to optimise the benefit-risk profile.

There are also 11 individual recommendations: four are unchanged from the previous version, six have been modified, combined or reformulated and one is new.

NSAIDs may be offered as first treatment but should not be used alone if there is evidence that the disease may be severe.

For people with peripheral arthritis (most people with this disease), prompt initiation of treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs), with methotrexate preferred. If this strategy fails to achieve the treatment goal, then treatment with biologic DMARDs should be initiated, but there is no class preference for this group of patients.

EULAR also suggests the possibility of using Janus kinase inhibitors after failure of biologic DMARDs or when biologic DMARDs are not appropriate. Apremilast may be suggested in specific cases.

An algorithm is also suggested for people with predominant axial or enthesitic disease. Traditional synthetic DMARDs are not used for these patients; The axial form of the disease responds well to tumor necrosis factor inhibitors (TNFi) or IL-17 inhibitors.

The choice of mechanism of action should take into account extramusculoskeletal manifestations, with specific recommendations for people with skin, gut, or eye involvement.

For example, in people with cutaneous psoriasis, treatment should be directed toward biologic-modifying antirheumatic drugs (biologics or bDMARDs) that target interleukins, and there are now four classes to choose from: IL-12/23 inhibitors, IL-23p19 inhibitors, IL-17A inhibitors, and IL-17A/F inhibitors. People with uveitis should receive monoclonal TNFi, and people with inflammatory bowel disease should use drugs approved for this disease (TNFi, IL-12/23 inhibitor, Janus kinase inhibitor, in some cases IL-23p19 inhibitor).

In addition to treatment recommendations, the publication also addresses topics such as drug switching and dose reduction for patients in sustained remission. EULAR hopes that these practical and updated recommendations will be useful for both healthcare professionals and their patients, and that they will support access to optimal treatment for people with PsA.

The work is published in the Annals of the Rheumatic Diseases journal.