Management of Peripheral Arthritis in Patients With Psoriatic Arthritis: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations

Abstract

ObjectiveWe aimed to compile evidence for the efficacy and safety of therapeutic options for the peripheral arthritis domain of psoriatic arthritis (PsA) for the revised 2021 Group in Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations.MethodsA working group consisting of clinicians and patient research partners was convened. We reviewed the evidence from new randomized controlled trials (RCTs) for PsA treatment from February 19, 2013, to August 28, 2020. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-informed approach to derive evidence for the classes of therapeutic options for 3 patient groups: (1) naïve to treatment, (2) inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and (3) inadequate response to biologic DMARDs (bDMARDs). Recommendations were derived through consensus meetings.ResultsThe evidence review included 69 RCTs. We derived GRADE evidence for each class of therapeutic options and achieved consensus for the recommendations. For patients naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and phosphodiesterase 4 inhibitors, and emphasizes regular assessment and early escalation to achieve treatment target. bDMARDs (tumor necrosis factor inhibitors [TNFi], interleukin 17 inhibitors [IL-17i], IL-12/23i, IL-23i) and Janus kinase inhibitors (JAKi) are also strongly recommended. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i, and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i, and JAKi. The evidence supporting nonpharmacological interventions was very low. An expert panel conditionally recommends adequate physical activity, smoking cessation, and diet to control weight gain.ConclusionEvidence supporting optimal therapy for the peripheral arthritis domain of PsA was compiled for the revised 2021 GRAPPA treatment recommendations.

Dynamics of inflammation-associated plasma proteins following faecal microbiota transplantation in patients with psoriatic arthritis and healthy controls: exploratory findings from the FLORA trial

“…3 Inducer, enhancer and effector cytokines, such as IL-23, IL-17 and TNF, respectively, orchestrate the inflammatory disease process in PsA 4 and are currently the main therapeutic targets of cytokine inhibition. 5 Despite expansion of the pharmacological toolbox within the last 20 years, obtaining sustained remission remains a considerable clinical challenge in PsA. 5 6 The accumulating evidence implicating the intestinal milieu as a potential disease initiator and/or modifier of PsA inflammation has motivated investigation into the immunomodulatory potential of interventions targeting the complex interaction between host and gut microbes.…”

Application of clinical and molecular profiling data to improve patient outcomes in psoriatic arthritis

“…There are now a wide range of effective therapeutic options available in the clinic for the treatment of PsA, including conventional synthetic Disease-Modifying AntiRheumatic Drugs (DMARDs) (in this case methotrexate), biologic cytokine inhibitors targeting Tumour Necrosis Factor (TNF) and the IL-23/IL-17 pathway and targeted synthetic DMARDs (in the form of Janus Kinase (JAK) inhibitors). 49 , 50 While welcome, this plethora of options presents a dilemma for clinicians when choosing the best therapy for an individual with PsA, as treatment responses are not uniform between patients or even between domains in the same individual. A significant proportion of patients with PsA do not respond to the administered therapeutic agent.…”

Current treatment strategies and recommendations in psoriatic arthritis

“…15 Despite the low quality of evidence to support the use of conventional synthetic DMARDs for peripheral arthritis, it is still strongly recommended because of the reasonable response seen in observational studies, [16][17][18][19] good experience of use, and universal accessibility. 20 We now have a high level of evidence supporting TNF inhibitors as superior to methotrexate as a first-line therapy for patients with active peripheral diseases, particularly for those with early stage PsA. [17][18][19] Very importantly, a treat-to-target strategy, consideration of patients' comorbidities, and shared decisionmaking are the overarching principles of management.…”

“…For the axial domain, TNF and IL‐17 inhibitors were both strongly recommended 15 . Despite the low quality of evidence to support the use of conventional synthetic DMARDs for peripheral arthritis, it is still strongly recommended because of the reasonable response seen in observational studies, 16–19 good experience of use, and universal accessibility 20 . We now have a high level of evidence supporting TNF inhibitors as superior to methotrexate as a first‐line therapy for patients with active peripheral diseases, particularly for those with early stage PsA 17–19 .…”