EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update

Abstract

ObjectiveTo update the European League Against Rheumatism (EULAR) recommendations for the pharmacological treatment of psoriatic arthritis (PsA).MethodsAccording to the EULAR standardised operating procedures, a systematic literature review was followed by a consensus meeting to develop this update involving 28 international taskforce members in May 2019. Levels of evidence and strengths of recommendations were determined.ResultsThe updated recommendations comprise 6 overarching principles and 12 recommendations. The overarching principles address the nature of PsA and diversity of both musculoskeletal and non-musculoskeletal manifestations; the need for collaborative management and shared decision-making is highlighted. The recommendations provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs and local glucocorticoid injections are proposed as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis accompanied by factors such as dactylitis or joint damage, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumour necrosis factor (TNF), interleukin (IL)-17A or IL-12/23 should be initiated, taking into account skin involvement if relevant. If axial disease predominates, a TNF inhibitor or IL-17A inhibitor should be started as first-line disease-modifying antirheumatic drug. Use of Janus kinase inhibitors is addressed primarily after bDMARD failure. Phosphodiesterase-4 inhibition is proposed for patients in whom these other drugs are inappropriate, generally in the context of mild disease. Drug switches and tapering in sustained remission are addressed.ConclusionThese recommendations provide stakeholders with an updated consensus on the pharmacological management of PsA, based on a combination of evidence and expert opinion.

Musculoskeletal Ultrasound in Monitoring Clinical Response to Treatment in Acute Symptomatic Psoriatic Dactylitis: Results from a Multicentre Prospective Observational Study

“…Patients did not show axial involvement. Since dactylitis was the only active manifestation of PsA, patients were only treated with a local steroid injection or oral NSAIDs, according to local and international recommendations [ 8 , 9 , 24 ]. Forty-two fingers were injected with local steroid, while 41 were managed with NSAIDs (ibuprofen or etoricoxib).…”

“…The measurement of dactylitis severity varies from a simple count of the affected fingers to the Leeds Dactylitis Index (LDI) and LDI-basic (LDI-b), which evaluate finger circumference and tenderness [ 6 , 7 ]. The Group for Research and Assessment of Psoriasis and PsA (GRAPPA) [ 8 ] and the European League Against Rheumatism (EULAR) [ 9 ] recommend non-steroidal anti-inflammatory drugs (NSAIDs) and local corticosteroid injections for symptomatic management.…”

Defining Pre-Clinical Psoriatic Arthritis in an Integrated Dermato-Rheumatology Environment

“…Historically, dermatological treatments, including vitamin A and vitamin D analogues and biologic therapies including efalizumab and alefacept, were useful for treating skin disease, but had no proven benefit in joint disease. Likewise, the data for other compounds including ciclosporin is, at the population level, less than convincing for the therapy of PsA [ 60 ]. The evidence supporting Methotrexate (MTX) treatment for PsO is strong, while for PsA is controversial.…”

“…The evidence supporting Methotrexate (MTX) treatment for PsO is strong, while for PsA is controversial. Recommendations by both the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) support its use for peripheral arthritis [ 60 , 61 ]. In the recently published Study of Etanercept and Methotrexate in Subjects with Psoriatic Arthritis (SEAM-PsA), the authors described an unexpected high efficacy of MTX monotherapy in enthesitis and dactylitis domain [ 62 ].…”

Choosing the right treatment for patients with psoriatic arthritis

“…Traditionally, EULAR used an algorithmic approach that focused mainly on peripheral arthritis, 13 and in the recent updated recommendation, more considerations have been given to the other manifestations, namely polyarthritis, oligoarthritis, enthesitis, dactylitis and axial diseases. 14 …”