Guideline offers recommendations on treatment of psoriatic arthritis

A tumor necrosis factor (TNF) inhibitor biologic agent is the preferred first-line therapy for treatment-naive patients with active psoriatic arthritis, according to a new guideline from the American College of Rheumatology and the National Psoriasis Foundation.

The guideline is based on a systematic literature review examining evidence on the benefits and harms of available pharmacologic and nonpharmacologic therapies for psoriatic arthritis. A voting panel determined the direction and strength of the recommendations, with 6% considered strong and 94% considered conditional. The guideline was published by Arthritis & Rheumatology on Nov. 30, with simultaneous publication by Arthritis Care & Research and the Journal of Psoriasis and Psoriatic Arthritis.

The guideline offered the following additional recommendations for treatment-naive patients:

• Oral small-molecule (OSM) inhibitors, which are low-molecular-weight substances that are able to enter cells directly to exert their clinical activity (such as phosphodiesterase-4 and Janus kinase inhibitors), may be used instead of a TNF inhibitor biologic agent in patients with active disease, those without severe psoriatic arthritis and without severe psoriasis, those who prefer oral over parenteral treatment, and those with contraindications to TNF inhibitor therapy, such as congestive heart failure or recurrent infections.
• A TNF inhibitor biologic agent is recommended over an interleukin (IL)-17 inhibitor biologic agent or an IL-12/23 inhibitor biologic agent. An IL-17 inhibitor biologic agent or an IL-12/23 inhibitor biologic agent may be used instead of TNF inhibitor biologic agents in patients who have severe psoriasis or contraindications to TNF inhibitor biologics.
• OSM inhibitors are preferred over the IL drugs. IL drugs may be considered in patients with severe psoriasis or severe psoriatic arthritis.
• Methotrexate is preferred over NSAIDs in patients with active disease. NSAIDs can be considered before methotrexate in patients with less active disease after careful consideration of cardiovascular and renal risks.
• An IL-17 inhibitor biologic agent is preferred over an IL-12/23 inhibitor biologic agent. The latter may be considered in patients with concomitant irritable bowel disease or in those who prefer less frequent drug administration.

The guideline also offered recommendations on treating psoriatic arthritis that remains active despite OSM inhibitor treatment, treatment with a TNF inhibitor biologic agent as monotherapy or combination therapy, treatment with an IL-17 inhibitor biologic agent as monotherapy, and treatment with an IL-12/23 inhibitor biologic agent as monotherapy, among other topics.

Regarding nonpharmacological interventions, the guideline recommends that patients with active psoriatic arthritis participate in some form or combination of exercise, physical therapy, occupational therapy, massage therapy, and acupuncture. Low-impact exercise is recommended over high-impact exercise, although the latter can be done according to patients' preference if no contraindications are present. The guideline stressed that clinicians should encourage patients to stop smoking. Weight loss is recommended in patients who are overweight or obese, the guideline said.

The guideline authors noted that most of their recommendations are conditional and are based on low-quality evidence. “The conditional recommendations convey that, although the suggested course of action will be best for many patients, there will be some patients in whom, considering their comorbidities and/or their values and preferences, the alternative represents the best choice,” the authors wrote. “The guideline will be updated as new evidence from comparative studies becomes available.”