Joint ACR/NPF Psoriatic Arthritis Treatment Guidelines Emphasize Treat-to-Target Approach

Conditional recommendations include TNFi as first-line

A wealth of new treatments for psoriatic arthritis (PsA) in recent years has prompted the development of new treatment guidelines, released jointly by the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) in December 2018.

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“It’s great that we have more treatment options for our patients, but until these guidelines, there was no evidence-based algorithm for how to use them,” says M. Elaine Husni, MD, MPH, staff in the Department of Rheumatic and Immunologic Diseases and a member of the guidelines committee. “These guidelines represent the best of what we have that’s evidence-based.”

But most of the recommendations remain conditional, she adds. “The data is limited. It’s not ethical to withdraw treatment, we have few head-to-head trials, and so we compiled a group of experts to deliver consensus-based statements to guide treatment.”

For the first time, that group of experts included patients with PsA. Two patients served on a voting panel with healthcare professionals, and a patient panel of nine adults with PsA provided insights on their experience which were incorporated into panel discussions.

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“The patient panel is novel for treatment guidelines and allows recommendations to be more representative of what patients really experience,” says Dr. Husni.

Notable recommendations

  • Use a treat-to-target approach for all patients with active disease (conditional)
  • Prescribe TNF inhibitor (TNFi) biologics as first-line therapy for treatment naïve patients with active PsA (conditional)
  • Choose oral small molecule (OSM) drugs for nonsevere disease, patient preference for oral therapy or contraindications to TNFi (conditional)
  • Switch to a TNFi or an IL-17 or LI-12/23 inhibitor instead of another OSM if active disease persists with OSM therapy (conditional)
  • Urge patients to quit smoking (strong)

The guidelines also address treatment in the presence of comorbidities including inflammatory bowel disease, diabetes and serious infections and other issues like enthesitis, psoriatic spondylitis and vaccinations.

Impact and future directions

According to Dr. Husni, these guidelines move us closer to optimal treatments for inflammatory arthritis. “The treat-to-target approach has been well-known in rheumatoid arthritis, but it now also has validity in psoriatic arthritis,” she says. “Couple this with the recommendation of TNF inhibitors as first-line treatment for treatment naïve patients with active disease, and I think these guidelines will have lasting impact on how we treat our patients.”

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Dr. Husni also urges more focus on nonpharmacologic approaches to treatment. The recommendation for smoking cessation is a significant step in the right direction, but more research is needed in other areas, such as the relationship between obesity and PsA. “We are also studying ways to decrease the primary comorbidities of the disease, including cardiovascular disease,” she adds. “There is always more to be done for our patients.”