Table 1. Recommendations for the Initial Treatment of Patients With Active PsA Who Are OSM- and Other Treatment-Naïve

Table 2. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an OSM

Table 3. Recommendations for Treatment of Patients With Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX

Table 4. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an IL-17i or an IL-12/23i Biologic Monotherapy

Table 5. Recommendations for Treatment of Patients With Active PsA Including Treat-To-Target, Active Axial Disease, Enthesitis, or Active IBD

Table 6. Recommendations for Treatment of Patients With Active PsA and Comorbidities, Including Concomitant Diabetes and Recurrent Serious Infections

Table 7. Recommendations for Vaccination in Patients With Active PsA

Table 8. Recommendations for Treatment of Patients With Active PsA With Nonpharmacologic Interventions

Document Overview

Design and created by Guideline Central in participation with the American College of Rheumatology and National Psoriasis Foundation.

Treatment of Psoriatic Arthritis

American College of Rheumatology

National Psoriasis Foundation

Publication Date: Nov 30, 2018

Page Last Updated: May 5, 2026

Recommendation Grading

Grade Definitions on Strength of Recommendation and Guide to Interpretation
Strength	Wording in the guideline	For the patient	For the clinician
Strong	"should use" or "should be used"	Most individuals in this situation would want the recommended course and only a small proportion would not.	Most individuals should receive the recommended course of action. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.
Conditional	"may be used" or "may consider" or "Y (less preferred drug) may be used instead of X (preferred drug)" or "may consider Y instead of X (preferred drug)"	The majority of individuals in this situation would want the suggested course, but many would not.	Different choices would be appropriate for different patients. Decision aids may be useful in helping individuals in making decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working towards a decision.

Grade Definitions of Quality and Certainty of the Evidence
Quality Grade	Definition
High	Very confident that the true effect lies close to that of the estimate of the effect.
Moderate	Moderately confident in the effect estimate. The true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low	Confidence in the estimate is limited. The true effect may be substantially different from the estimate of effect.
Very low	Very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

Document Overview

Document Title: Treatment of Psoriatic Arthritis

Authoring Societies

American College of Rheumatology

National Psoriasis Foundation

Document Publication Date: Nov 30, 2018

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: onlinelibrary.wiley.com/doi/full/10.1002/acr.23789

Source Citation: Singh, J.A., Guyatt, G., Ogdie, A., Gladman, D.D., Deal, C., Deodhar, A., Dubreuil, M., Dunham, J., Husni, M.E., Kenny, S., Kwan‐Morley, J., Lin, J., Marchetta, P., Mease, P.J., Merola, J.F., Miner, J., Ritchlin, C.T., Siaton, B., Smith, B.J., Van Voorhees, A.S., Jonsson, A.H., Shah, A.A., Sullivan, N., Turgunbaev, M., Coates, L.C., Gottlieb, A., Magrey, M., Nowell, W.B., Orbai, A.‐M., Reddy, S.M., Scher, J.U., Siegel, E., Siegel, M., Walsh, J.A., Turner, A.S. and Reston, J. (2019), 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care Res, 71: 2-29. doi:10.1002/acr.23789

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

Scope: Management, Treatment

Diseases/Conditions (MeSH)

D015535 - Arthritis, Psoriatic

Keywords: PsA, psoriatic arthritis

Target Patient Population: Adults with active psoriatic arthritis

Target Provider Population: Rheumatologists, dermatologists and other clinicians who manage PsA in adults

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resource: Data Supplement

Number of Source Documents: 137

Literature Search End Date: Thursday, March 8, 2018

Includes peer/external review process?: Yes

Includes public comment process?: Yes

Methodologist involvement?: Yes

Patient involvement?: Yes

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

Identifies study selection process?: Yes

Identifies study selection criteria?: Yes

Identifies methods used to evaluate and analyze the evidence?: Yes

Identifies key questions addressed by the systematic review?: Yes

Identifies search strategy?: Yes

Treatment of Psoriatic Arthritis

Table 1. Recommendations for the Initial Treatment of Patients With Active PsA Who Are OSM- and Other Treatment-Naïve

In OSM- and other treatment–naïve patients with active PsA:

Treat with a TNFi biologic over an OSM (MTX, SSZ, LEF, CSA, or APR)

Treat with a TNFi biologic over an IL-17i biologic

Treat with a TNFi biologic over an IL-12/23i biologic

Treat with an OSM over an IL-17i biologic

Treat with an OSM over an IL-12/23i biologic

Treat with MTX over NSAIDs

Treat with an IL-17i biologic over an IL-12/23i biologic

Table 2. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an OSM

In adult patients with active PsA despite treatment with an OSM

Switch to a TNFi biologic over a different OSM

Switch to a TNFi biologic over an IL-17i biologic

Switch to a TNFi biologic over an IL-12/23i biologic

Switch to a TNFi biologic over abatacept

Switch to a TNFi biologic over tofacitinib

Switch to an IL-17i over a different OSM

Switch to an IL-17i biologic over an IL-12/23i biologic

Switch to an IL-17i biologic over abatacept

Switch to an IL-17i biologic over tofacitinib

Switch to an IL-12/23i biologic over a different OSM

Switch to an IL-12/23i biologic over abatacept

Switch to an IL-12/23i biologic over tofacitinib

Add apremilast to current OSM therapy over switching to apremilast

Switch to another OSM (except apremilast) over adding another OSM (except apremilast) to current treatment

Switch to a TNFi biologic monotherapy over MTX and a TNFi biologic combination therapy

Switch to an IL-17i biologic monotherapy over MTX and an IL-17i biologic combination therapy

Switch to an IL-12/23i biologic monotherapy over MTX and an IL-12/23i biologic combination therapy

Table 3. Recommendations for Treatment of Patients With Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy:

Switch to a different TNFi biologic over switching to an IL-17i biologic

Switch to a different TNFi biologic over switching to an IL-12/23i biologic

Switch to a different TNFi biologic over switching to abatacept

Switch to a different TNFi biologic over switching to tofacitinib

Switch to a different TNFi biologic (with or without MTX) over adding MTX to the same TNFi biologic monotherapy

Switch to an IL-17i biologic over switching to an IL-12/23i biologic

Switch to an IL-17i biologic over abatacept

Switch to an IL-17i biologic over tofacitinib

Switch to an IL-12/23i biologic over abatacept

Switch to an IL-12/23i biologic over tofacitinib

Switch to a different TNFi biologic monotherapy over switching to a different TNFi biologic and MTX combination therapy

Switch to an IL-17i biologic monotherapy over switching to an IL-17i biologic and MTX combination therapy

Switch to an IL-12/23i biologic monotherapy over switching to an IL-12/23i biologic and MTX combination therapy

In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy:

Switch to a different TNFi biologic + MTX over switching to a different TNFi biologic monotherapy

Switch to an IL-17i biologic monotherapy over an IL-17i biologic and MTX combination therapy

Switch to IL-12/23i biologic monotherapy over IL-12/23i biologic and MTX combination therapy

Table 4. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an IL-17i or an IL-12/23i Biologic Monotherapy

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy:

Switch to a TNFi biologic over switching to an IL-12/23i biologic

Switch to a TNFi biologic over switching to a different IL-17i biologic

Switch to a TNFi biologic over adding MTX to an IL-17i biologic

Switch to an IL-12/23i biologic over switching to a different IL-17i biologic

Switch to an IL-12/23i biologic over adding MTX to an IL-17i biologic

In adult patients with active PsA despite treatment with an IL-12/23i biologic monotherapy:

Switch to a TNFi biologic over switching to an IL-17i biologic

Switch to a TNFi biologic over adding MTX to an IL-12/23i biologic

Switch to an IL-17i biologic over adding MTX to an IL-12/23i biologic

Table 5. Recommendations for Treatment of Patients With Active PsA Including Treat-To-Target, Active Axial Disease, Enthesitis, or Active IBD

In adult patients with active PsA:

Use a treat-to-target strategy over not following a treat-to-target strategy

In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs:a

Switch to a TNFi biologic over switching to an IL-17i biologic

Switch to a TNFi biologic over switching to an IL-12/23i biologic

Switch to an IL-17i biologic over switching to an IL-12/23i

In adult patients with active PsA and predominant enthesitis who are both OSM- and biologic treatment-naïve:

Start oral NSAIDs over an OSM (specifically apremilast)

Start a TNFi biologic over an OSM (specifically apremilast)

Start tofacitinib over an OSM (specifically apremilast)

In adult patients with active PsA and predominant enthesitis despite treatment with OSM:b

Switch to a TNFi biologic over an IL-17i biologic

Switch to a TNFi biologic over an IL-12/23i biologic

Switch to a TNFi biologic over switching to another OSM

Switch to an IL-17i biologic over an IL-12/23i biologic

Switch to an IL-17i biologic over switching to another OSM

Switch to an IL-12/23i biologic over switching to another OSM

In adult patients with active PsA and concomitant active IBD who are both OSM- and biologic treatment-naïve:

Start a monoclonal antibody TNFi biologic over an OSM

In adult patients with active PsA and concomitant active IBD despite treatment with an OSM:

In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs:^a

In adult patients with active PsA and predominant enthesitis despite treatment with OSM:^b

In adult patients with active PsA needing vaccinations:^a