What Do Guidelines Say About Treatment Options?

There is no one standard of care for psoriatic arthritis (PsA), 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 guidelines for PsA are changing rapidly with new treatments and continued research adding new information and options for people with PsA. Each individual should talk to their doctor to make the ultimate judgment on treatment with regards to their unique circumstances.

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 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. In addition, the GRAPPA guidelines note that the goal of treatment should be remission, with low disease activity if remission is not possible.1,2

GRAPPA Recommendations1

Peripheral arthritis Skin and nail diseases Axial (spinal) disease Dactylitis (sausage-like swelling of fingers and/or toes) Enthesitis (swelling at ligament and tendon attachment points)
Disease-modifying antirheumatic drugs (DMARD) – Methotrexate, sulfasalazine, leflunomide TNF inhibitors NSAID TNF inhibitors TNF inhibitors
Tumor necrosis factor (TNF) inhibitors IL-12/23 inhibitors Physiotherapy Corticosteroid injections IL-12/23 inhibitors
Non-Steroidal Anti-Inflammatory Drugs (NSAID) Topical therapies TNF inhibitors DMARDs – Methotrexate, sulfasalazine, leflunomide NSAID
Oral corticosteroids DMARDs – Methotrexate, leflunomide, cyclosporine A Corticosteroid injections IL-12/23 inhibitors Physiotherapy
Corticosteroid injections IL-12/23 inhibitors Bisphosphonates IL-17 inhibitors Corticosteroid injections (with extreme caution)
PDE-4 inhibitor IL-17 inhibitors IL-12/23 inhibitors PDE-4 inhibitor IL-17 inhibitors
Interleukin (IL)-12/23 inhibitors PDE-4 inhibitor IL-17 inhibitors PDE-4 inhibitor PDE-4 inhibitor

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. Clinical recommendations were developed on the best available evidence and later reviewed and approved by the AAD Board of Directors.3

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.3

AAD Guidelines3

Mild psoriatic arthritis
Moderate to severe psoriatic arthritis
  • Methotrexate (alone or in combination with cyclosporine)
  • TNF inhibitors

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.4

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. Like the GRAPPA guidelines, the EULAR guidelines also state that the goal of treatment should be remission of the disease or minimal/low disease activity if remission is not possible.5

EULAR Guideline5

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
NSAID
Methotrexate
TNF inhibitors
Change the DMARD
Corticosteroid injections
Leflunomide
DMARDs
PDE-4 inhibitor
Sulfasalazine
IL inhibitor
PDE-4 inhibitor
Written by: Emily Downward | Last reviewed: April 2018.
View References
  1. Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016 May;68(5):1060-71. doi: 10.1002/art.39573. Epub 2016 Mar 23.
  2. Coates LC, FitzGerald O, Merola JF, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis/Outcome Measures in Rheumatology Consensus-Based Recommendations and Research Agenda for Use of Composite Measures and Treatment Targets in Psoriatic Arthritis. Arthritis Rheumatol. 2018 Mar;70(3):345-355. doi: 10.1002/art.40391. Epub 2018 Feb 6.
  3. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 6. Guidelines of care for treatment of psoriasis and psoriatic arthritis: case-based presentation and evidence-based conclusions. J Am Acad Dermatol. 2011;65:137-74.
  4. European League Against Rheumatism (EULAR). Available at http://eular.org/. Accessed 4/5/18.
  5. 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.