Draft Psoriatic Arthritis Guideline Presented at ACR 2017

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SAN DIEGO — The authors of the updated American College of Rheumatology (ACR)/National Psoriasis Foundation (NPF) guideline for psoriatic arthritis (PsA) presented their draft recommendations at the 2017 ACR/ARHP Annual Meeting.

The guideline includes pharmacologic and nonpharmacologic recommendations for treating adult patients with active psoriatic arthritis, defined as disease causing symptoms at an unacceptably bothersome level as reported by the patient. The authors conducted a meta-analysis of 83 studies to develop the guideline, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Jasvinder Singh, MD, MPH, principal investigator and voting panel leader, from the University of Alabama at Birmingham, presented the recommendations at the meeting. He explained that the majority of the recommendations (94%) are conditional, due to a lack of high-quality evidence.

“There needs to be an active discussion between the physician and the patient with regard to which treatment to choose,” Dr Singh stated. He added that when physicians and patients decide not to use the first-line treatment, the guideline provides defined, specific conditions under which a secondary treatment may be preferred.

A summary of the draft recommendations is as follows:               

Patient with active PsA who is treatment naive

• Begin with a tumor necrosis factor inhibitor (TNFi) biologic over an oral small molecule (OSM) agent, IL17i biologic, or IL12/23i biologic
  • Does patient continue to have active PsA despite TNFi biologic therapy? Switch to a different TNFi biologic* over IL17i biologic, IL12/23i biologic, abatacept, tofacitinib, or adding methotrexate (MTX)
  • Is PsA still active? Switch to IL17i biologic* over IL12/23i biologic, abatacept, or tofacitinib
  • Does active PsA persist? Switch to IL12/23i biologic* over abatacept or tofacitinib
  • Does patient continue to have active PsA despite TNFi biologic with MTX combination therapy?
    • Switch to a different TNFi biologic plus MTX over TNFi biologic monotherapy
    • Switch to IL17i biologic monotherapy over IL17i biologic plus MTX
    • Switch to IL12/23i biologic monotherapy over IL 12/23i biologic with MTX

• Choose OSM over IL17i biologic or IL 12/23i biologic
  • Patient still has PsA despite OSM: Switch to TNFi biologic* over another OSM, IL17i biologic, IL12/23i biologic, abatacept, or tofacitinib
  • Does active PsA persist TNFi biologic monotherapy? Switch to IL17i biologic* over another OSM, IL12/23i biologic, abatacept, or tofacitinib
  • Does patient continue to have active PsA despite IL17i biologic therapy? Switch to IL12/23i biologic* over another OSM, abatacept, or tofacitinib

• Start MTX over nonsteroidal anti-inflammatory drugs (NSAIDs)

• Begin IL17i biologic before IL12/23i biologic
  • Is PsA active despite IL17i biologic monotherapy? Switch to TNFi biologic over IL 12/23i biologic, a different IL 17i  biologic, or adding MTX
    • Is PsA still active? Switch to IL22/23i biologic over a different IL17i biologic or adding MTX
  • Is PsA active despite IL12/23i biologic monotherapy? Switch to TNFi biologic over IL17i biologic or adding MTX
    • Is PsA still active? Switch to IL17i over adding MTX

*Biologic therapy is recommended over biologic-with-MTX combination therapy

Patient with active PsA spondylitis/axial disease despite NSAIDs

• Switch to TNFi biologic over IL17i biologic or 12/23i biologic
  • Is PsA still active? Switch to IL17i over IL12/23i

Patient with active PsA with predominant enthesitis

• Is the patient OSM and biologic naive? Start oral NSAIDs, TNFi biologic, or tofacitinib over apremilast
• Is PsA active despite OSM treatment? Switch to TNFi biologic over IL17i, IL12/23i or another OSM
  • Is PsA still active? Switch to IL17i biologic over IL12/23i or another OSM
    • Is PsA still active? Switch to IL12/23i biologic over another OSM

Patient with active PsA with concomitant active inflammatory bowel disease (IBD)

• Is the patient OSM and biologic naive? Switch to TNFi monoclonal antibody biologic over OSM
• Is PsA active despite OSM treatment?
  • Switch to TNFi monoclonal antibody biologic over TNFi receptor biologic or IL 17i biologic (strong recommendation)
  • Switch to a TNFi monoclonal antibody biologic over IL 12/23i biologic
    • Is PsA still active? Switch to IL 12/23i biologic over IL 17i biologic (strong recommendation)

Patient with active PsA and concomitant comorbidities who is OSM and biologic naive

• Does patient have concomitant diabetes? Start OSM other than MTX over a TNFi biologic
• Does patient experience frequent serious infections?
  • Start OSM over TNFi biologic (strong recommendation)
  • Start IL12/23i biologic or IL17i biologic over TNFi biologic

Dr Singh also noted that more specific studies are needed for enthesitis, axial disease, and arthritis mutilans. More trials are also needed of nonpharmacologic interventions, patients with common comorbidities, and monotherapy vs combination therapy.

“The exciting thing about this particular guideline is the fact that the TNF inhibitor is the first line of treatment,” stated Dafna Gladman, MD, FRCPC, professor of medicine at the University of Toronto. “While there are patients who cannot use TNF inhibitors, at least we have a recommendation, conditional as it may be, for the use of these drugs as a first-line treatment.”

The guideline is currently under peer review and will be published in early 2018 in Arthritis and Rheumatology, Arthritis Care and Research, and the Journal of Psoriasis and Psoriatic Arthritis.

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Reference

Ogdie A, Singh JA, Siegel E, Gladman DD, Husni ME. Treatment of psoriatic arthritis: a new ACR/NPF clinical guideline. Presented at: 2017 ACR/ARHP Annual Meeting; November 3-8, 2017; San Diego, CA. Scientific Session 5T064.