Treatment Guidelines for Psoriatic Arthritis

Reviewed by: HU Medical Review Board | Last reviewed: August 2022

The goal of treatment for people living with psoriatic arthritis (PsA) is to delay or avoid joint damage. At this time, there is no one standard of care for psoriatic arthritis (PsA). But treatments are changing at a rapid pace. More drugs and therapies are available now than ever before.1

PsA is a complex disease to treat

PsA is hard to diagnose and treat. There are many reasons for this, including:2,3

  • Symptoms vary widely from person to person.
  • Symptoms are often ignored, missed, or diagnosed as something else.
  • Symptoms can come and go.
  • Symptoms can change over time.

PsA is also linked to other conditions like inflammatory bowel disease (IBD), diabetes, obesity, hypertension, fatty liver disease, anxiety, and depression. These conditions can further complicate PsA treatment. Taking these health problems into account can help you choose the best PsA treatment for you.1

Treatment guidelines help to streamline care

In order to provide you with the best outcome, several organizations have developed treatment guidelines. Treatment guidelines for PsA help:1

  • Educate doctors on the best treatment methods to use
  • Keep people updated on the latest research findings
  • Promote standards for quality of care
  • Encourage efficiency in available resources
  • Assess which knowledge gaps still need research

Types of treatment guidelines

There are 3 main treatment guidelines for PsA, but many others are in the works. Each is slightly different and based on the latest research. The 3 main treatment guidelines are:1,4

  • American College of Rheumatology / National Psoriasis Foundation (ACR/NPF)
  • Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
  • European League Against Rheumatism (EULAR)

All 3 of these guidelines suggest a “treat-to-target” approach. This means that your doctor sets a goal and monitors your response to the treatment, adjusting as needed. This is used for both drug-based therapies and non-drug therapies.1,4

ACR/NPF guidelines

In 2018, the ACR and NPF developed new guidelines for PsA treatment. Their guidelines differ from others because they recommend giving certain biologic drugs that fight inflammation as the first step of treatment. These drugs are called tumor necrosis factor (TNF) inhibitors.4

The ACR/NPF guidelines recommend that drug treatment takes place in the following order. If the TNF inhibitors tried first do not work, then doctors should move on to the next type of medicine in the list.4

  • TNF inhibitors such as etanercept, infliximab, adalimumab, golimumab, certolizumab pegol
  • Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, leflunomide, cyclosporine, or apremilast
  • Interleukin (IL) 17i drugs such as secukinumab, ixekizumab, brodalumab
  • IL12/23i biologic drugs (ustekinumab)
  • CTLA4-Ig drugs (abatacept)
  • Janus kinase (JAK) inhibitor drugs (tofacitinib)

The order in which your doctor will try these drugs may change depending on whether you:4

  • Have severe PsA or psoriasis
  • Prefer to take pills over shots
  • Have other health issues like congestive heart failure, IBD, serious infections, or nerve diseases
  • Have had a serious reaction to a TNF inhibitor

Other non-drug treatments mentioned in the ACR/NPF guidelines include:4

GRAPPA guidelines

According to GRAPPA guidelines, the goals of therapy are to:4,5

  • Achieve the lowest possible level of disease activity in all areas
  • Maximize joint function
  • Improve quality of life and well-being
  • Minimize structural damage to the greatest extent possible
  • Avoid or minimize complications, both from untreated active disease and from therapy

The GRAPPA guidelines break down their recommended order of treatment by disease category.

For people with peripheral arthritis, they recommend:5

  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroid injections
  • DMARDs – methotrexate, sulfasalazine, leflunomide
  • TNF inhibitors

For people with skin and nail diseases, they recommend:5

  • Topical therapies
  • Phototherapy
  • DMARDs – methotrexate, leflunomide, cyclosporine A
  • TNF inhibitors

For people with spinal (axial) disease, they recommend:5

  • NSAIDs
  • Physiotherapy
  • TNF inhibitors

For people with sausage-like swelling of fingers and/or toes (dactylitis), they recommend:5

  • NSAIDs
  • Corticosteroid injections
  • TNF inhibitors
  • DMARDs – methotrexate, sulfasalazine, leflunomide

For people with swelling where the ligaments and tendons attach (enthesitis), they recommend:5

  • NSAIDs
  • Physiotherapy
  • TNF inhibitors

EULAR guidelines

The EULAR guidelines include NSAIDs, steroids, and DMARDs. Like GRAPPA and ACR/NPF, the goal of the EULAR treatment guidelines is remission or low disease activity.6

Phase I:6

  • Diagnosis of active PsA
  • NSAIDs
  • Combine with short-term steroids

Phase II, if phase I treatments are not working:6

  • Start methotrexate, leflunomide, or sulfasalazine

Phase III, if phase II treatments are not working or if there is any sign of toxicity:6

  • Start biological DMARD (bDMARD), usually a TNF inhibitor
  • Other bDMARD options: IL-17 inhibitor, IL-12/23 inhibitor
  • If bDMARD is not appropriate, start JAK inhibitor

Phase IV, if phase III treatments are not working or if there is any sign of toxicity:6

  • Change the bDMARD or JAK inhibitor, or switch to PDE-4 inhibitor

It is important to note that every person’s PsA treatment will be different. Consult with your doctor about which treatment plan will work best for you.

Personalized treatment is key

These guidelines aim to help you achieve the best treatment outcome possible. PsA guidelines can change fast as new drugs and new research are released. Talk with your doctor about your options and to decide which treatments are right for you.