ATLANTA - The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) have released a joint treatment guideline for psoriatic arthritis (PsA) that provides evidence-based pharmacologic and non-pharmacologic recommendations on caring for treatment-naïve patients with active PsA and patients who continue to have active PsA despite treatment. It also includes recommendations for vaccinations, psoriatic spondylitis, predominant enthesitis, and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections.
PsA is a chronic inflammatory musculoskeletal disease most commonly found in patients with psoriasis, a skin disease that causes red, scaly patches to appear on the skin. According to the NPF, more than 8 million Americans suffer from psoriasis, and it is estimated that 30 percent of them may develop PsA.
Some key recommendations from the guideline include:
- A conditional recommendation to use treat-to-target approach for all patients with active PsA;
- A conditional recommendation to use tumor necrosis factor inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA; and
- A strong recommendation for smoking avoidance/cessation.
"Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation," said Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama at Birmingham who served as principal investigator for the guideline project. "The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation."
The use of TNFi biologics as a first-line therapy was one of many recommendations included to help providers and patients decide between the various pharmacologic options currently available. While current GRAPPA recommendations address the use of TNFi biologics in treatment-naïve patients, this is the first guideline that specifically recommends first trying them over oral small molecule (OSM) drugs.
"The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first," said Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and member of the NPF Medical Board who served as a content expert on the guideline's core team. "This doesn't hold true once other symptoms and comorbidities are present, so OSMs can continue to be a first-line option for patients that have contraindications to TNFi treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy. Providers should take into consideration all active disease domains, comorbidities, and the patient's functional status when choosing the optimal therapy for an individual at a given point in time."
Tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs.
The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics; the benefits of smoking cessation; and the well-established link of smoking with mortality, cancers and heart and lung diseases in the general population.
The PsA guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. Due to limited data in some areas, the quality of evidence was often graded low or very low. This led to nearly all recommendations being conditional. A voting panel of rheumatologists, dermatologists, health professionals, and patients achieved consensus on the direction and the strength of the recommendations.
"Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions," said Singh. "This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations."
About the American College of Rheumatology
The American College of Rheumatology (ACR) is an international medical society representing over 9,400 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit http://www.rheumatology.org.
About the National Psoriasis Foundation
Serving its community through more than 50 years of patient support, advocacy, research funding, and education, the National Psoriasis Foundation (NPF) is the world's leading nonprofit fighting for individuals with psoriasis and psoriatic arthritis. The NPF mission is to drive efforts to cure psoriatic disease and dramatically improve the lives of more than 8 million Americans affected by this chronic immune-mediated disease. As part of that effort, NPF created its Patient Navigation Center to offer personalized assistance to everyone with psoriasis or psoriatic arthritis. To date, NPF has funded more than $19 million in research grants and fellowships that help drive discoveries that may lead to more and better treatments and ultimately a cure. Learn more at http://www.psoriasis.org.