What Do Guidelines Say About Treatment Options?


There is no one standard of care for psoriatic arthritis, and with such a varied disease, there are multiple approaches to treatment. Several professional organizations have created guidelines to describe appropriate care based on the best scientific evidence available and broad consensus. The goal of these guidelines is to provide optimal strategies to help patients achieve optimal outcomes, based on comprehensive reviews of research and expert opinion. However, the physician and the patient must make the ultimate judgment on treatment with regards to the individual circumstances of the patient.

GRAPPA Guidelines

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) is an international group of physicians from different disciplines, including rheumatology, dermatology and specialties such as methodology. GRAPPA also collaborates with patient partners and biopharmaceutical industry representatives. The GRAPPA guidelines were developed based on information gathered from patients via face-to-face meetings and online surveys to create the 6 overarching principles, which are based on the key manifestations of psoriatic arthritis. Then researchers reviewed current literature and abstracts from scientific meetings to craft the new recommendations, using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) method. The guidelines were recently updated in 2015 to reflect the latest research and new therapy options now available. The GRAPPA guidelines include recommendations for all six key manifestations of psoriatic arthritis – peripheral arthritis, axial involvement, enthesitis, dactylitis, and skin and nail diseases – as well as related comorbidities, including cardiovascular disease, diabetes, and obesity.1,2

GRAPPA Guidelines3

Peripheral arthritis Skin and nail diseases Axial disease (spine) Dactylitis (sausage-like swelling of fingers and/or toes) Enthesitis (swelling at ligament and tendon attachment points)
Non-Steroidal Anti-Inflammatory Drugs (NSAID) Topicals NSAID NSAID NSAID
Intra-articular steroids Light therapy Physical therapy Corticosteroid injections Physical therapy
Disease-Modifying Antirheumatic Drugs (DMARD) DMARD Biologics Biologics Biologics
Biologics Biologics

AAD Guidelines

The American Academy of Dermatology (AAD), the professional physician association of dermatologists, convened a working group of recognized experts to create guidelines for the treatment of psoriasis and psoriatic arthritis. The group reviewed published articles spanning the years 1960 through 2010 (only English-language publications) and graded evidence on quality. Clinical recommendations were developed on the best available evidence and later reviewed and approved by the AAD Board of Directors.4,5

Because psoriatic arthritis most often develops after psoriasis, dermatologists are in a unique position to be able to identify early signs of psoriatic arthritis. With these guidelines, the AAD encourages dermatologists to actively seek signs and symptoms of psoriatic arthritis during every patient visit, and refer patients to a rheumatologist for further evaluation. Treatment recommendations are provided for the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis.4,5

AAD Guidelines4

Mild psoriatic arthritis
Moderate psoriatic arthritis
  • Biologics
  • Biologics

EULAR Guidelines

The European League Against Rheumatism (EULAR) is a scientific and educational association that represents people with arthritis/rheumatism, health professionals and scientific societies of rheumatology from all the European nations. 6

The EULAR guidelines are based on evidence from systematic literature reviews for various psoriatic arthritis treatments, including non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, synthetic and biological disease-modifying anti-rheumatic drugs (DMARDs). To create the guidelines, EULAR convened a 35-member task force to review, discuss and summarize the evidence. The task force considered all non-topical pharmacological therapies. Ten recommendations were developed for treatment from each of the different categories of drugs for both articular (joint) and extra-articular manifestations of psoriatic arthritis.7

EULAR Guideline8

Phase I: Diagnosis of active psoriatic arthritis
Phase II: Lack of efficacy and/or toxicity in phase I
Phase III: Lack of efficacy and/or toxicity in phase II, predominantly axial disease, or enthesitis
Phase IV: Lack of efficacy and/or toxicity in phase III
Start NSAID and/or corticosteroid injections
Tumor necrosis factor (TNF) inhibitor
Change the biologic, switch to second TNF-inhibitor and/or DMARD
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view references
  1. Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): Treatment Recommendations for Psoriatic Arthritis 2015 [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/group-for-research-and-assessment-of-psoriasis-and-psoriatic-arthritis-grappa-treatment-recommendations-for-psoriatic-arthritis-2015/. Accessed online on 5/11/16.
  2. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). Accessed online on 5/1//16 at http://www.grappanetwork.org.
  3. Ritchlin CT, Kavanaugh A, Gladman DD, Mease PJ, Helliwell P, Boehncke WH, de Vlam K, Fiorentino D, Fitzgerald O, Gottlieb AB, McHugh NJ, Nash P, Qureshi AA, Soriano ER, Taylor WJ; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009 Sep;68(9):1387-94.
  4. Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, Van Voorhees AS, Elmets CA, Leonardi CL, Beutner KR, Bhushan R, Menter A. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008 May;58(5):851-64.
  5. Medscape. Accessed online on 5/11/16 at http://www.medscape.com/viewarticle/737796.
  6. European League Against Rheumatism (EULAR), Accessed online on 5/11/16 at http://eular.org/.
  7. Ramiro S, Smolen JS, Landewé R, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis. 2016 Mar;75(3):490-8.
  8. Gossec L, Smolen JS, Gaujoux-Viala C, et al. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann Rheum Dis. 2012;71(1):4-12.
View Written By | Review Date
Written by: Emily Downward | Last reviewed: October 2016.
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