Psoriatic Arthritis Assessment and Treatment

Last updated July 25, 2022

Key Points

Key Points

  • The substantial expansion of treatment options and therapeutic approaches for psoriatic arthritis (PsA) in recent years can present challenges to busy clinicians selecting optimal therapies for their patients.
  • This Pocket Guide presents updated treatment recommendations for medication selection in PsA developed by GRAPPA members and patient research partners (PRPs).

Figure 1. Core Domains and Related Conditions


Treatment

Treatment

Overarching Principles

  • These recommendations, which include the most current data concerning the optimal therapeutic approaches to PsA, present contextual considerations to empower shared decision-making.
  • The ultimate goals of therapy for all patients with PsA are:
    • To achieve the lowest possible level of disease activity in all domains of disease. As definitions of remission and low or minimal disease activity become accepted, these will be included in the goal
    • To optimize functional status, improve quality of life and wellbeing, and prevent structural damage to the greatest extent possible
    • To avoid or minimize complications, both from untreated active disease and from therapy
  • Assessment of patients with PsA requires consideration of all disease domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, skin psoriasis, psoriatic nail disease, uveitis and IBD. The impact of disease on pain, function, quality of life and structural damage should be examined.
  • Clinical assessment ideally includes patient-reported measures with a comprehensive history and physical examination, often supplemented by laboratory tests and imaging techniques (for example, X-ray, ultrasound or MRI). The most widely accepted metrics that have been validated for PsA should be utilized whenever possible.
  • Comorbidities and related conditions should be considered and their impact on the approach to the condition and its treatment addressed appropriately. Such conditions include obesity, metabolic syndrome, cardiovascular disease, depression and anxiety, liver disease (for example, non-alcoholic fatty liver disease), chronic infections, malignancy, bone health (for example, osteoporosis), central sensitization (for example, fibromyalgia) and reproductive health. Multidisciplinary and multispeciality assessment and management may be most beneficial for individual patients.
  • Therapeutic decisions need to be individualized and are made jointly by the patient and their clinician. Treatment should reflect patient preferences, with patients being provided with the best information concerning relevant options. Treatment choices may be affected by various factors, including disease activity, previous therapies, prognostic factors such as structural damage, comorbid conditions and patient factors such as cost, convenience and choice.
  • Ideally, patients should be reviewed promptly, offered regular evaluation by appropriate specialists, and have treatment adjusted as needed in order to achieve the goals of therapy. Early diagnosis and treatment is likely to be of benefit.

Biosimilars

  • Biosimilars must be approved through a robust regulatory review. “Biomimics” or “intended copies” are not biosimilars. This may require ongoing education for both patients and clinicians’ education to ensure a thorough understanding.
  • Periodic re-evaluation of biosimilar products after their initial approval would be important to ensure ongoing quality.
  • Extrapolation to PsA, even when no studies of a given biosimilar were conducted in PsA, is acceptable. Ideally, additional studies specifically in PsA can be conducted if they were not part of the initial approval process.
  • Patients and clinicians must be involved in decisions about switching.
  • Pharmacovigilance is crucial; naming conventions need to allow tracking of specific agents and batches.
  • Multiple switches need to be studied in a rigorous fashion on an ongoing basis.
  • Savings realized from the use of biosimilars should be utilized to improve access for larger numbers of patients.
  • Immunogenicity is a potential concern that should be monitored on an ongoing basis.

Tapering/Discontinuing Therapy

  • For patients who achieve the goals of therapy (for example, ideally remission, or low disease activity if remission is not achievable), tapering and ultimately discontinuing therapy may be considered.
  • Potential benefits of tapering may include lesser risks of adverse effects as well as pharmacoeconomic benefits.
  • The decision to taper therapy should be with the patients’ thorough understanding and direct involvement.
  • Discussions between patient and clinician should inform the optimal approach to tapering for each individual (for example, decreasing dosages, increasing treatment intervals, appropriate time intervals for making changes).
  • Patients and clinicians need to understand that the potential drawbacks of tapering include:
    • Reactivation of disease activity, with the possibility that re-achievement of the target may not be immediate and may not always be achieved
    • At present it is not possible to predict a priori which patients might be able to successfully taper, which patients may be able to come off all medications, and which patients will not be able to taper at all
    • Although focused on active domains such as peripheral arthritis, it is not known how tapering of effective therapy might influence other outcomes, such as the increased risk of cardiovascular disease presumably related to systemic inflammation

Table 1. Summary of Recommendations for Treatment of PsA

Peripheral arthritis, DMARD naive

csDMARDs (except CsA), TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i ( S )
638
NSAIDs, oral GC, IA GC ( C )
638

Peripheral arthritis, DMARD inadequate response

TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i ( S )
638
csDMARDs, NSAIDs, oral GC, IA GC, CTLA4-Ig ( C )
638

Peripheral arthritis, bDMARD experienced

TNFi, IL-17i, IL-23i, JAKi ( S )
638
NSAIDs, oral GC, IA GC, IL-12/23i, PDE4i, CTLA4-Ig ( C )
638

Axial disease, bDMARD naive

NSAIDs, physiotherapy, simple analgesia, TNFi, IL-17i, JAKi ( S )
638
GC SIJ injections, bisphosphonates ( C )
638
PDE4i ( C (Not) )
638
csDMARDs ( S (NOT) )
638
IL-12/23i, IL-23i (No recommendation: insufficient or conflicting evidence) ()
638

Enthesitis

TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i ( S )
638
NSAIDs, physiotherapy, MTX, CTLA4-Ig, GC injections (with extreme caution) ( C )
638
Other csDMARDs (No recommendation: insufficient or conflicting evidence) ()
638

Dactylitis

TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i ( S )
638
NSAIDs, GC injections, MTX, CTLA4-Ig ( C )
638
Other csDMARDs ( C (Not) )
638

Psoriasis (plaque)

Topical therapies, phototherapy, csDMARDs (MTX, fumarate, fumaric acid esters, CsA), TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i, JAKi ( S )
638
Acitretin ( C )
638

Nail psoriasis

TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i ( S )
638
Topical GC, tacrolimus and calcipotriol combination or individual therapies, pulsed dye laser, csDMARDs (MTX, LEF, CsA), acitretin, JAKi ( C )
638
Topical CsA, tazarotene, fumarate, fumaric acid esters, UVA and UVB phototherapy, alitretinoin (No recommendation: insufficient or conflicting evidence) ()
638

IBD: Crohn’s disease

TNFi (not ETN), IL-12/23i ( S )
638
IL-23i, JAKi, MTX ( C )
638
IL-17i ( S (NOT) )
638
ETN (No recommendation: insufficient or conflicting evidence) ()
638

IBD: UC

TNFi (not ETN), IL-12/23i ( S )
638
IL-23i, JAKi, MTX ( C )
638
IL-17i ( S (NOT) )
638
ETN, PDE4i (No recommendation: insufficient or conflicting evidence) ()
638

Uveitis

TNFi (not ETN), CsA, MTX ( C )
638
ETN ( C (Not) )
638
Other csDMARDs, IL-17i, IL-12/23i (No recommendation: insufficient or conflicting evidence) ()
638

Figure 2. GRAPPA 2021 Treatment Schema

Bold text indicates a strong recommendation, standard text indicates a conditional recommendation.

a Conditional recommendation based on data from abstracts only.

Table 2. Summary of Recommendations for Treatment of PsA in the Case of Comorbidities

Comorbidity NSAIDs GCs MTX and/or LEF TNFi IL-17i IL-12/23i, IL-23i JAKi PDE4i
Elevated risk of cardiovascular disease (CVD) Caution Caution
Congestive heart failurea Caution Avoid
Elevated risk for venous thromboembolism (VTE) Caution
Obesity Caution
Fatty liver disease Avoid
Active hepatitis B or C Avoid Caution Caution Caution Caution Caution
HIV Caution Caution Caution Caution Caution
Tuberculosis Caution Caution Caution Caution Caution
History of recent malignancy Caution Caution Caution Caution Caution
Multiple sclerosis (MS) and/or demyelinating disease Avoid
Depression and/or anxiety Caution
a Severe or advanced; class III or IV according to the New York Heart Association (NYHA) Functional Classification.

Recommendation Grading

Abbreviations

  • CTLA4-Ig: CTLA4-immunoglobulin Fusion Protein
  • CVD: Cardiovascular Disease
  • CsA: Ciclosporin
  • DMARDs: Disease-modifying Antirheumatic Drugs
  • ETN: Etanercept
  • GC: Glucocorticoid(s)
  • GRAPPA: Group For Research And Assessment Of Psoriasis And Psoriatic Arthritis
  • IA: Intra Articular
  • IBD: Inflammatory Bowel Disease
  • IL-23i: IL-23 Inhibitor
  • IL12/23i: Interleukin 12/23 Inhibitor
  • IL17i: Interleukin 17 Inhibitor
  • IL6i: Interleukin 6 Inhibitor
  • JAK: Janus Kinase
  • JAKi: Janus Kinase Inhibitor
  • LEF: Leflunomide
  • MS: Multiple Sclerosis
  • MTX: Methotrexate
  • NSAIDs: Non-Steroidal Anti-Inflammatory Drugs
  • PDE4: Phosphodiesterase 4
  • PDE4i: Phosphodiesterase 4 Inhibitor [apremilast]
  • PRP: Patient Research Partners
  • PsA: Psoriatic Arthritis
  • SIJ: Sacroiliac Injections
  • SSZ: Sulfasalazine
  • TNFi: Tumor Necrosis Factor Inhibitor
  • UC: Ulcerative Colitis
  • VTE: Venous Thromboembolism
  • bDMARD: Biologic DMARD
  • csDMARD: Conventional Synthetic DMARD (MTX, SSZ, LEF, CsA; Unless Otherwise Specified)

Source Citation

Coates LC, Soriano ER, Corp N, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021. Nat Rev Rheumatol (2022). https://doi.org/10.1038/s41584-022-00798-0

Disclaimer

This pocket guide attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This pocket guide should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.

Codes

ICD-10 Codes

Code Descriptor Documentation Concepts Quality/Performance
K51.911 Ulcerative colitis, unspecified with rectal bleeding Type, complications/manifestations RXHCC67, HCC35
K51.80 Other ulcerative colitis without complications Type, complications/manifestations RXHCC67, HCC33
E13.0 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) Type, complications/manifestations, due to/caused by, temporal factors RXHCC30, HCC17
L40.52 Psoriatic arthritis mutilans RXHCC82, HCC40
E11.0 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) Type, Cause, Complication/ Manifestation
K51.90 Ulcerative colitis, unspecified, without complications Type, complications/manifestations RXHCC67, HCC35
E66.1 Drug-induced obesity Type, due to/caused by
F32.0 Major depressive disorder, single episode, mild Type Episode HCC58, RXHCC131
B97.35 Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere Type RXHCC, HCC1
O98.711 Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester Type, complications/manifestations, stage
B20 Human immunodeficiency virus [HIV] disease Type RXHCC, HCC1
E09.0 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) Type, Cause, Complication/ Manifestation
K73.0 Chronic persistent hepatitis, not elsewhere classified Type, temporal factors HCC29