Treatment Guidelines for Psoriatic Arthritis

There is no one standard of care for psoriatic arthritis (PsA). Because it is such a varied disease, there can be many ways to treat it. Several professional organizations have created treatment guidelines for doctors to follow. Each is slightly different and based on the latest science of the time. The goal of treatment should be to delay or avoid joint damage as much as possible.

These guidelines aim to help people achieve the best outcome possible. Keep in mind, PsA guidelines can change quickly as new drugs and new research are released. You will need to talk with your doctor to decide which treatments are right for you.

American College of Rheumatology (ACR)/National Psoriasis Foundation (NPF) guidelines

In 2018, the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) developed new guidelines for the treatment of psoriatic arthritis. The guidelines apply to 2 groups of people:1

  • Those who have never taken the recommended drugs (treatment naïve)
  • People who have not responded to treatment.

"Treat to target" approach

These guidelines differ from others because it recommends TNFi biologics first for most people. Most other recommendations suggest methotrexate as the first drug for treatment. The ACR/NPF guidelines also suggest “treat to target.” This means your doctor will set a goal and monitor your response to the drugs often, adjusting as needed.1

While everyone is different, the treatments for PsA generally should be tried in this order:1

  • Tumor necrosis factor inhibitor (TNFi) biologics such as etanercept, infliximab, adalimumab, golimumab, certolizumab pegol
  • Methotrexate, sulfasalazine, leflunomide, cyclosporine, or apremilast
  • Interlukin (IL) 17i such as secukinumab, ixekizumab, brodalumab
  • IL12/23i biologic (ustekinumab)
  • CTLA4-Ig (abatacept)
  • JAK inhibitor (tofacitinib)

The order in which your doctor will try these drugs may change depending on whether you:1

  • Have mild to moderate PsA or mild to moderate psoriasis
  • Prefer to take pills over shots
  • Have congestive heart failure, serious infections, or certain nerve diseases
  • Have severe psoriasis
  • Have had a serious reaction to a TNFi biologic

For people with active PsA despite treatment and who also have inflammatory bowel disease (IBD), the guidelines recommend trying drugs in this order:1

  • TNFi like infliximab, adalimumab, golimumab, or certolizumab pegol
  • TNFi etanercept
  • IL12/23i biologics
  • IL 17i biologics (Not recommended as they are not effective for IBD)

For people with active PsA and frequent serious infections who have not tried some of the most common treatments:1

  • Methotrexate, sulfasalazine, leflunomide, cyclosporine, or apremilast

Stopping smoking is strongly recommended because it causes PsA drugs like biologics to work less well.

Other non-drug treatments mentioned include:

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) guidelines

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) is an international group of doctors from rheumatology, dermatology and other specialties, patient partners, and the biopharmaceutical industry. The GRAPPA guidelines were created using information gathered from people with PsA and current scientific findings. The goals of therapy include:2,3

  • To achieve the lowest possible level of disease activity in all domains of disease
  • To optimize functional status, improve quality of life and well-being, and minimize structural damage to the greatest extent possible

To avoid or minimize complications, both from untreated active disease and from therapy

Guidelines based on 6 symptoms of psoriatic arthritis

The GRAPPA guidelines include recommendations for all 6 main symptoms of PsA: peripheral arthritis, axial involvement, enthesitis, dactylitis, and skin and nail diseases. The guidelines also cover related comorbidities, including heart disease, diabetes, and obesity. The GRAPPA guidelines recommend that remission or low disease activity should be the goal of treatment.2,3

Peripheral arthritis

  • Disease-modifying antirheumatic drugs (DMARD) – Methotrexate, sulfasalazine, leflunomide
  • Tumor necrosis factor (TNF) inhibitors
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroid pills
  • Corticosteroid injections
  • PDE-4 inhibitor
  • Interleukin (IL)-12/23 inhibitors

Skin and nail diseases

  • TNF inhibitors
  • IL-12/23 inhibitors
  • Topical therapies
  • DMARDs – Methotrexate, leflunomide, cyclosporine A
  • IL-12/23 inhibitors
  • IL-17 inhibitors
  • PDE-4 inhibitor

Axial (spinal) disease

  • Physiotherapy
  • TNF inhibitors
  • Corticosteroid injections
  • Bisphosphonates
  • IL-12/23 inhibitors
  • IL-17 inhibitors

Dactylitis (sausage-like swelling of fingers and/or toes)

  • TNF inhibitors
  • Corticosteroid injections
  • DMARDs – Methotrexate, sulfasalazine, leflunomide
  • IL-12/23 inhibitors
  • IL-17 inhibitors
  • PDE-4 inhibitor

Enthesitis (swelling at ligament and tendon attachment points)

  • TNF inhibitors
  • IL-12/23 inhibitors
  • Physiotherapy
  • Corticosteroid injections (with extreme caution)
  • IL-17 inhibitors
  • PDE-4 inhibitor

American Academy of Dermatology guidelines

The American Academy of Dermatology (AAD) gathered a group of experts to create guidelines for the treatment of psoriasis and psoriatic arthritis. Their recommendations were created based on the best available evidence.4

Treating both psoriasis and psoriatic arthritis

Because psoriatic arthritis most often develops after psoriasis, dermatologists are in a unique position to spot early signs of PsA. With these guidelines, the AAD encourages dermatologists to look for signs of psoriatic arthritis during every patient visit. If PsA is suspected, the person should be referred to a rheumatologist. Treatment recommendations include the use of topical (skin) treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis.4

Mild psoriatic arthritis

  • Steroids

Moderate to severe psoriatic arthritis

  • Methotrexate (alone or in combination with cyclosporine)
  • TNF inhibitors

European League Against Rheumatism (EULAR) guidelines

The European League Against Rheumatism (EULAR) is a scientific and educational association for people with arthritis/rheumatism and their doctors.5

The EULAR guidelines are based on evidence from many studies of various psoriatic arthritis treatments, including NSAIDs, steroids, and DMARDs. To create the guidelines, EULAR hosted a task force of 35 experts to review the evidence. The task force looked at all non-topical drug therapies. Twelve recommendations were made for treatment of joint and non-joint symptoms of PsA. Like the GRAPPA guidelines, the EULAR guidelines state that remission or minimal/low disease activity is the goal of treatment.6

Phase I:

  • Diagnosis of active psoriatic arthritis
  • Methotrexate
  • Start leflunomide or sulfasalazine
  • Combine with short-term glucocorticoids

Phase II: Lack of efficacy and/or toxicity in phase I

  • Add a BDMARD or JAK-inhibitor
  • Change to or add a synthetic DMARD

Phase III: Lack of efficacy and/or toxicity in phase II, predominantly axial disease, or enthesitis

  • TNF inhibitors
  • DMARDs
  • PDE-4 inhibitor

Phase IV: Lack of efficacy and/or toxicity in phase III

  • Change the bMARD or JAK-inhibitor

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Written by: Emily Downward | Last reviewed: February 2021.