During the past 2 decades, greater insight into the immunopathophysiology of psoriatic arthritis (PsA) has been gained, along with refinement in outcomes and assessments, introduction of novel therapeutic agents, and development of newer treatment approaches. The 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations represent the latest update and were developed to facilitate the care of patients with PsA. The revised recommendations were published recently in Nature Reviews Rheumatology.

The updated GRAPPA recommendations are intended for all clinicians who care for patients with PsA. The GRAPPA recommendations use a domain-based approach, which spans the 6 domains of PsA, which include peripheral arthritis, axial disease, enthesitis, dactylitis, skin psoriasis, and nail psoriasis.

The recommendations also include important comorbidities that may have a potential impact on treatment. In contrast to the 2015 recommendations, these new recommendations split the comorbidities into “related conditions” (comprising inflammatory bowel disease and uveitis) and “comorbidities” (allowing for a slightly different approach to extra-musculoskeletal disease-related manifestations and other comorbidities).


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A Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-informed methodology was used to offer a transparent approach to rating the quality of evidence supporting the recommendations. There were 2 additional topical issues included — the use of biosimilars and the tapering of therapy — both of which were addressed by the development of new position statements. Up-to-date recommendations were developed regarding the use of therapies for the 6 domains of PsA, related conditions, and comorbidities.

Overall, 8 subcommittees were formed: 1 for each of the 6 PsA domains, 1 for the related conditions, and 1 for comorbidities. All of the GRAPPA members were invited to participate, and were asked to select a preferred and an alternative subcommittee in which to participate. All interested members were grouped into the subcommittees according to their preferences, with the goal being to have 15 to 20 members per group.

The subcommittees developed and refined population, intervention, comparator, and outcomes (PICO) questions initially within their own subcommittee, then within the methodologists and the steering committee. Based on the PICO questions, a strategy was designed for the main evidence review and a literature search was conducted. The literature search was limited to publications from 2013 onward in order to identify new data that had been published since the creation of the 2015 recommendations, including conference presentations from 2017 to 2020.

Individual subcommittees used a GRADE-informed approach, taking into account the quality of the evidence for therapies in an effort to generate recommendations for each of the domains, which were incorporated into an overall schema. Because safety issues frequently affect potential therapeutic selections, additional consideration was afforded to all relevant comorbidities.

Research Topics

Among the research topics identified by the GRAPPA members in the updated recommendations were:

  • Screening and early diagnosis
  • Precision medicine
  • Treatment strategy and sequencing
  • Special populations
  • Response to treatment
  • Disease impact
  • Safety considerations
  • Cardiometabolic disease
  • Care delivery, which has been impacted by the COVID-19 pandemic.

Limitations of the recommendations include the fact that the evidence was derived from patients with PsA who predominantly had polyarthritis, with this evidence then extrapolated to oligoarthritis and the other phenotypes. For inadequate responders, insufficient data are available to render specific recommendations based on primary vs secondary failure of prior therapy.

According to the authors, “Choice of therapy for an individual should ideally address all disease domains active in that patient, supporting shared decision-making.” In order to achieve optimal outcomes for all patients with PsA, “clinicians need to be aware of [the] important advances” in the revised GRAPPA treatment recommendations.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Coates LC, Soriano ER, Corp N, et al; GRAPPA Treatment Recommendations domain subcommittees. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021. Nat Rev Rheumatol. 2022;18(8):465-479. doi:10.1038/s41584-022-00798-0