Treatment Guidelines for Psoriatic Arthritis

There is no one standard of care for psoriatic arthritis (PsA). 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.

American College of Rheumatology/National Psoriasis Foundation guidelines

In 2018, the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) developed new guidelines for the treatment of psoriatic arthritis. These guidelines differ from others because it recommends TNFi biologics first for most people.

The ACR/NPF guidelines also suggest “treat to target.” 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
  • Interleukin (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

  • Severity of the arthritis or 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
  • IL12/23i biologics

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 also strongly recommended because it causes PsA drugs like biologics to work less well.

Other non-drug treatments mentioned include:1

  • Physical therapy, occupational therapy, or massage therapy
  • Weight loss
  • Exercise

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis guidelines

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) guidelines were created using information gathered from people with PsA and current scientific findings. The goals of therapy include:2,3

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

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

  • NSAID
  • 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
  • NSAID
  • Physiotherapy
  • Steroid injections (with extreme caution)
  • IL-17 inhibitors
  • PDE-4 inhibitor

American Academy of Dermatology guidelines

The American Academy of Dermatology (AAD) created guidelines for the treatment of psoriasis and psoriatic arthritis.4

Because psoriatic arthritis most often develops after psoriasis, dermatologists are in a unique position to spot early signs of PsA. The AAD encourages dermatologists to look for signs of psoriatic arthritis during every 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 people with psoriasis and psoriatic arthritis.4,5

Mild psoriatic arthritis

  • NSAID
  • Steroids

Moderate to severe psoriatic arthritis

  • Methotrexate (alone or in combination with cyclosporine)
  • TNF inhibitors such as infliximab and adalimumab
  • Other biologics including IL-12/IL-23 and IL-17 inhibitors

European League Against Rheumatism (EULAR) guidelines
The European League Against Rheumatism (EULAR) guidelines include NSAIDs, steroids, and DMARDs. 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
  • NSAIDs
  • Combine with short-term steroids

Phase II: Lack of efficacy or toxicity in phase I

  • Start methotrexate, leflunomide, or sulfasalazine

Phase III: Lack of efficacy or toxicity in phase II, mostly axial disease, or enthesitis

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

Phase IV: Lack of efficacy or toxicity in phase III

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

Guidelines aim to help people achieve the best outcome possible. 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.

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