GRAPPA Psoriatic Arthritis Assessment and Treatment Guideline Pocket Guide

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.

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 failure^a	—	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

^aSevere or advanced; class III or IV according to the New York Heart Association (NYHA) Functional Classification.

Strength of Recommendations in GRADE<sup>a</sup>

GRADE	Strength	Interpretation	Implications for clinicians	Implications for policymakers
S	Strongly in favor	Almost all informed patients would choose to receive the intervention	Should be accepted by most patients to whom it is offered	Should be adopted as policy
C	Conditionally in favor	Most informed patients would choose the intervention, but a sizable minority would not	Large role for education and shared decision-making	Requires stakeholder engagement and discussion
C NOT	Conditionally against	Most informed patients would not choose the intervention, but a small minority would	Large role for education and shared decision-making	Requires stakeholder engagement and discussion
S NOT	Strongly against	Most patients should not receive the intervention	Should not be offered to patients	Should be adopted as policy

^a www.guidelinedevelopment.org/handbook

Abbreviations

bDMARD: biologic DMARD

CsA: ciclosporin

csDMARD: conventional synthetic DMARD (MTX, SSZ, LEF, CsA; unless otherwise specified)

CTLA4-Ig: CTLA4-immunoglobulin fusion protein

CVD: cardiovascular disease

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

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 resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.

Psoriatic Arthritis Assessment and Treatment

Key Points

Figure 1. Core Domains and Related Conditions

Treatment

Overarching Principles

Biosimilars

Tapering/Discontinuing Therapy

Table 1. Summary of Recommendations for Treatment of PsA

Peripheral arthritis, DMARD naive

Peripheral arthritis, DMARD inadequate response

Peripheral arthritis, bDMARD experienced

Axial disease, bDMARD naive

Enthesitis

Dactylitis

Psoriasis (plaque)

Nail psoriasis

IBD: Crohn’s disease

IBD: UC

Uveitis

Figure 2. GRAPPA 2021 Treatment Schema

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

Strength of Recommendations in GRADE<sup>a</sup>

Abbreviations

Source Citation

Disclaimer