Psoriatic arthritis (PsA) is a chronic, immune-mediated inflammatory arthritis that occurs most commonly in some people with psoriasis, a skin condition characterized by red, scaly patches. Research suggests that approximately 20-30% of people with psoriasis also develop PsA, with the majority of patient’s presenting with skin-related disease that precedes the onset of arthritis symptomatology, though for ~15% skin and arthritic manifestations coincide in onset, and ~15% experiencing arthritic symptoms that occur before skin manifestations are present.
Today, we are going to look at two notable sets of guidelines for managing PsA published by GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) and ACR/NPF (American College of Rheumatology/National Psoriasis Foundation) for a side-by-side comparison of guideline developmental approach, scope, and treatment recommendations.
- Treatment of Psoriatic Arthritis
- Published by the ACR/NPF on November 30, 2018
- Psoriatic Arthritis Assessment and Treatment
- Published by the GRAPPA on June 27, 2022
It is worth mentioning that the GRAPPA Guidelines have a global perspective and are relevant in healthcare settings worldwide while the ACR/NPF guidelines are tailored to the US healthcare system and may include considerations specific to the American healthcare system.
| Approach | GRAPPA | ACR/NPF |
|---|---|---|
| Publication Date | June 27, 2022 | November 30, 2018 |
| Methodology | GRADE | GRADE |
| Grades Strength of Recommendation | Yes | Yes |
| Graded Level of Evidence | No | Yes |
| Based on Systematic Review | Yes | Yes |
| Multidisciplinary Panel | Yes | Yes |
| Methodologist Involvement | Yes | Yes |
| Patient Representative(s) | Yes | Yes |
| Literature Search Through | November 2020 | March 2018 |
Scope and Content:
- The guidelines provided by GRAPPA encompass a wide array of topics pertaining to the diagnosis, evaluation, and treatment of Psoriatic Arthritis (PsA). These guidelines include recommendations for both pharmacologic and non-pharmacologic interventions, as well as guidance on monitoring disease activity and addressing comorbidities.
- In contrast, the guidelines established by the ACR/NPF focus specifically on the pharmacologic management of PsA. These guidelines offer recommendations for the utilization of disease-modifying antirheumatic drugs (DMARDs), biologic therapies, and targeted synthetic DMARDs.
Pharmacological Differences and Similarities Between the Guidelines:
| Medications | GRAPPA | ACR/NPF |
|---|---|---|
| TNFi | Strongly Recommended For: Peripheral PsA, DMARD Naive Peripheral PsA, DMARD Inadequate Response Peripheral PsA, bDMARD experienced Axial disease, bDMARD naive Enthesitis Dactylitis Plaque Psoriasis Nail Psoriasis IBD (not ETN) Conditionally Recommended for: Uveitis | Recommended For: Active PsA Who Are OSM-and Other Treatment-Naïve Active PsA Despite Treatment With an OSM Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX Active PsA Despite Treatment With an IL-17i or an IL-12/23i Biologic Monotherapy Active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs Active PsA and predominant enthesitis who are both OSM- and biologic treatment–naive Active PsA and predominant enthesitis despite treatment with OSM Active PsA and concomitant active IBD who are both OSM- and biologic treatment–naive Active PsA and concomitant active IBD despite treatment with an OSM |
| IL-17i | Strongly Recommended For: Peripheral PsA, DMARD Naive Peripheral PsA, DMARD Inadequate Response Peripheral PsA, bDMARD experienced Axial disease, bDMARD naive Enthesitis Dactylitis Plaque Psoriasis Nail Psoriasis Conditionally Recommended for: IBD | Recommended For: Active PsA Who Are OSM-and Other Treatment-Naïve Active PsA Despite Treatment With an OSM Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX Active PsA Despite Treatment With an IL-12/23i Biologic Monotherapy Active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs Active PsA and predominant enthesitis despite treatment with OSM |
| IL-23i | Strongly Recommended For: Peripheral PsA, DMARD Naive Peripheral PsA, DMARD Inadequate Response Peripheral PsA, bDMARD experienced Enthesitis Dactylitis Plaque Psoriasis Nail Psoriasis Conditionally Recommended for: IBD | No addressed individually, separate from IL 12/23i |
| IL-12/23i | Strongly Recommended For: Peripheral PsA, DMARD Naive Peripheral PsA, DMARD Inadequate Response Enthesitis Dactylitis Plaque Psoriasis Nail Psoriasis IBD Conditionally Recommended for: Peripheral PsA, bDMARD experienced IBD | Recommended For: Active PsA Despite Treatment With an OSM Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX Active PsA Despite Treatment With an IL-17i Biologic Monotherapy Active PsA and predominant enthesitis despite treatment with OSM Active PsA and concomitant active IBD despite treatment with an OSM |
| JAKi | Strongly Recommended For: Peripheral PsA, DMARD Naive Peripheral PsA, DMARD Inadequate Response Peripheral PsA, bDMARD experienced Enthesitis Dactylitis Plaque Psoriasis Conditionally Recommended for: Nail Psoriasis IBD | Recommended For: Active PsA and predominant enthesitis who are both OSM- and biologic treatment–naive |
Treatment Sequencing and Switching:
- Both sets of guidelines offer recommendations for the sequencing of treatments and strategies for switching based on factors such as treatment response, disease activity, and patient preferences. The goal of these recommendations is to enhance disease control and reduce the occurrence of treatment-related adverse events.
Individualized Treatment Approach:
- Both the GRAPPA and ACR/NPF guidelines stress the significance of tailoring treatment to the individual, considering factors like disease severity, comorbidities, patient preferences, and treatment objectives when choosing and overseeing medications for PsA. Although there may be variations in the medication recommendations outlined in the GRAPPA and ACR/NPF guidelines for PsA, both sets of guidelines offer evidence-based direction to assist healthcare professionals in enhancing the management of this intricate condition and enhancing patient outcomes.
This concludes our Guidelines Side by Side for Psoriatic Arthritis published by GRAPPA and the ACR/NPF. We’ll see you next time for our next side-by-side guideline comparison! If there are any specific guidelines or topics you’re interested in seeing in this series feel free to reach out and don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.
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