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Psoriatic Arthritis

ACR and NPF Guidelines for the Treatment of Psoriatic Arthritis

Eric M. Ruderman, MD; Kenneth B. Gordon, MD 
Reviewed on May 15, 2023
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Introduction

In 2018, The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) published joint guidelines presenting evidence-based pharmacologic and nonpharmacologic recommendations for the treatment of active PsA, for both treatment-naïve and -experienced patients. The guidelines also provided recommendations for vaccinations and treatment in the presence of psoriatic spondylitis/axial disease, predominant enthesitis, active IBD, diabetes, or frequent serious infection. Of note, the vast majority (94%) of recommendations made in the ACR/NPF guidelines were conditional, and because of limited data, the quality of evidence was most often graded low or very-low. Nevertheless, some of the key recommendations included:

  • A conditional recommendation to use treat to target for all patients with active PsA
  • In treatment-naïve patients with active PsA, conditional recommendations to use a TNFi biologic over oral small molecule (OSM) drugs or an IL-17i or IL-12/…

Introduction

In 2018, The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) published joint guidelines presenting evidence-based pharmacologic and nonpharmacologic recommendations for the treatment of active PsA, for both treatment-naïve and -experienced patients. The guidelines also provided recommendations for vaccinations and treatment in the presence of psoriatic spondylitis/axial disease, predominant enthesitis, active IBD, diabetes, or frequent serious infection. Of note, the vast majority (94%) of recommendations made in the ACR/NPF guidelines were conditional, and because of limited data, the quality of evidence was most often graded low or very-low. Nevertheless, some of the key recommendations included:

  • A conditional recommendation to use treat to target for all patients with active PsA
  • In treatment-naïve patients with active PsA, conditional recommendations to use a TNFi biologic over oral small molecule (OSM) drugs or an IL-17i or IL-12/23i biologic. Treatment with an OSM is recommended over an IL-17i or IL-12/23i biologic. An IL-17i or IL-12/23i biologic may be used instead of TNFi biologics in patients with severe psoriasis or contraindications to TNFi biologics and may be used instead of OSMs in patients with severe psoriasis or severe PsA
  • In adult patients with active PsA despite treatment with an OSM, conditional recommendations to use a TNFi biologic over a different OSM, an IL-17i or IL-12/23i biologic, abatacept, or tofacitinib. Switching to an IL-17i biologic is recommended over an IL-12/23i biologic. Switching to an IL-17i or an IL-12/23i biologic is recommended over switching to a different OSM, abatacept, or tofacitinib
  • In adult patients with active PsA despite treatment with TNFi biologic monotherapy, conditional recommendations to switch to a different TNFi biologic over switching to an IL-17i or IL-12/23i biologic, abatacept, tofacitinib, or adding MTX to the current TNFi biologic monotherapy. Switching to an IL-17i biologic is recommended over an IL-12/23i biologic. Switching to an IL-17i or IL-12/23i biologic is recommended over abatacept or tofacitinib. An IL-17i or IL-12/23i biologic, abatacept, or tofacitinib may be used instead of a different TNFi biologic in the case of a primary TNFi biologic failure or a serious adverse event due to the TNFi biologic. An IL-17i or IL-12/23i biologic may also be used instead of a different TNFi biologic in the presence of severe psoriasis
  • A strong recommendation for smoking avoidance/cessation

The recommendations to use TNFi biologics as first-line therapy were made to help physicians decide between the numerous pharmacologic options currently available. Although the GRAPPA guidelines do address use of TNFi biologics in treatment-naïve patients, the ACR/NPF guidelines are the first to specifically recommend them over OSM drugs and other biologics, such as IL-17 inhibitors. Note that tofacitinib was not included in the OSM category as its risk/benefit profile distinguishes it from the other OSMs.

Key ACR/NPF treatment recommendations for different PsA patient groups are shown in Figure 6-12, Figure 6-13, Figure 6-14, and Figure 6-15. Many recommendations shown are conditional, meaning that the guideline panel believed that the desirable effects of the recommendations probably outweighed the undesirable effects, so the course of action would apply to most patients, but some may not want to follow the recommendations. As such, conditional recommendations are preference sensitive and always warrant a shared decision-making approach.

Enlarge  Figure 6-12: ACR/NPF Recommendations for the Treatment of Patients With Active PsA Who Are Treatment-Naïve. a May consider alternatives (indicated in parenthesis), if patient has severe psoriasis (IL17i or IL 12/23i biologic); has contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (OSM, IL 17i biologic, or IL12/23i biologic); prefers oral medications (OSM) or less frequent administrations (IL 12/23i biologic); has concern over starting biologic as the first therapy (OSM); or does not have severe psoriasis or severe PsA (OSM). b May consider alternatives (indicated in parentheses), if patients has severe psoriasis or severe PsA (IL12/23i biologic or IL 17i biologic); has concomitant active IBD (IL 12/23i biologic); or prefers less frequent administrations (IL 12/23i biologic). c May consider NSAIDs in patients with less active disease, after careful consideration of cardiovascular risks and renal risks of NSAIDs. d May consider IL 12/23i biologic if patient has concomitant IBD or desires less frequent drug administration. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
Figure 6-12: ACR/NPF Recommendations for the Treatment of Patients With Active PsA Who Are Treatment-Naïve. a May consider alternatives (indicated in parenthesis), if patient has severe psoriasis (IL17i or IL 12/23i biologic); has contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (OSM, IL 17i biologic, or IL12/23i biologic); prefers oral medications (OSM) or less frequent administrations (IL 12/23i biologic); has concern over starting biologic as the first therapy (OSM); or does not have severe psoriasis or severe PsA (OSM). b May consider alternatives (indicated in parentheses), if patients has severe psoriasis or severe PsA (IL12/23i biologic or IL 17i biologic); has concomitant active IBD (IL 12/23i biologic); or prefers less frequent administrations (IL 12/23i biologic). c May consider NSAIDs in patients with less active disease, after careful consideration of cardiovascular risks and renal risks of NSAIDs. d May consider IL 12/23i biologic if patient has concomitant IBD or desires less frequent drug administration. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
Enlarge  Figure 6-13: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment with OSMs. a For each biologic, biologic monotherapy is conditionally recommended over biologic + MTX combination therapy. b Add apremilast over switching to apremilast; switch to another OSM (except apremilast) over adding another OSM. c Please see Figure 6.12 for details and treatment options if patient has active PsA despite TNFi biologic. d Please see Figure 6.13 for details and treatment options if patient has active PsA despite IL17i or IL 12/23i biologic. e May consider alternatives (indicated in parentheses), if patient has severe psoriasis (IL 17i or IL 12/23i biologic); has contraindications to TNFi including recurrent infections, congestive heart failure, or demyelinating disease (OSM, IL 17i biologic, IL 12/23i biologic, abatacept, or tofacitinib); prefers oral medications (OSM, tofacitinib) or less frequent administrations (IL 12/23i biologic). f May consider alternatives (indicated in parentheses), if patient has concomitant active IBD (IL 12/23i biologic); absence of severe psoriasis or PsA (OSM); has recurrent serious infections (abatacept); has recurrent candida infections (tofacitinib); prefers oral medications (OSM, tofacitinib) or less frequent administrations (IL 12/23i biologic). g May consider alternatives (indicated in parentheses), if patient has absence of severe psoriasis or severe PsA (OSM); has recurrent or serious infections (abatacept); prefers oral medications (OSM, tofacitinib). The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
Figure 6-13: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment with OSMs. a For each biologic, biologic monotherapy is conditionally recommended over biologic + MTX combination therapy. b Add apremilast over switching to apremilast; switch to another OSM (except apremilast) over adding another OSM. c Please see Figure 6.12 for details and treatment options if patient has active PsA despite TNFi biologic. d Please see Figure 6.13 for details and treatment options if patient has active PsA despite IL17i or IL 12/23i biologic. e May consider alternatives (indicated in parentheses), if patient has severe psoriasis (IL 17i or IL 12/23i biologic); has contraindications to TNFi including recurrent infections, congestive heart failure, or demyelinating disease (OSM, IL 17i biologic, IL 12/23i biologic, abatacept, or tofacitinib); prefers oral medications (OSM, tofacitinib) or less frequent administrations (IL 12/23i biologic). f May consider alternatives (indicated in parentheses), if patient has concomitant active IBD (IL 12/23i biologic); absence of severe psoriasis or PsA (OSM); has recurrent serious infections (abatacept); has recurrent candida infections (tofacitinib); prefers oral medications (OSM, tofacitinib) or less frequent administrations (IL 12/23i biologic). g May consider alternatives (indicated in parentheses), if patient has absence of severe psoriasis or severe PsA (OSM); has recurrent or serious infections (abatacept); prefers oral medications (OSM, tofacitinib). The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
Enlarge  Figure 6-14: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment With a TNFI Biologic as Monotherapy or as Combination Therapy with MTX. <sup>a</sup> For each biologic, biologic monotherapy is conditionally recommended over biologic + MTX combination therapy. <sup>b</sup> May consider alternatives, if patient has primary TNFi biologic efficacy failure (IL 17i biologic, IL 12/23i biologic, abatacept, tofacitinib); has TNFi biologic-associated serious adverse event (IL 17i biologic, IL 12/23i biologic, abatacept, tofacitinib); patients have demonstrated partial response to the current TNFi biologic therapy, especially if the TNFi biologic is a monoclonal antibody (adding MTX); prefers an oral therapy tofacitinib); has severe psoriasis (IL17i); or patient prefers less frequent drug administration (IL 12/23i). <sup>c</sup> May consider alternatives (indicated in parentheses), if the patient has inflammatory bowel disease (IL 12/23i biologic, tofacitinib); prefers IV dosing (abatacept); has recurrent or serious infections (abatacept); prefers an oral therapy (tofacitinib); a history of recurrent candida infections (tofacitinib); or patient prefers less frequent drug administration (IL 12/23i). <sup>d</sup> May consider alternatives (indicated in parentheses), if patient prefers IV dosing (abatacept); has had recurrent or serious infections (abatacept); or prefers oral therapy (tofacitinib). <sup>e</sup> May consider the alternative, TNFi biologic monotherapy, if patient has demonstrated MTX-associated adverse events, prefers fewer medications or perceives MTX as a burden. <sup>f</sup> May consider the alternative, IL 17i biologic + MTX, if patient had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL 17i biologic was discussed as potentially beneficial to allow the new therapy time to work. <sup>g</sup> May consider the alternative, IL 12/23i biologic + MTX, if patient had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL 12/23i biologic was discussed as potentially beneficial to allow the new therapy time to work. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. <em>Arthritis Rheumatol</em>. 2019;71(1):5-32.
Figure 6-14: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment With a TNFI Biologic as Monotherapy or as Combination Therapy with MTX. a For each biologic, biologic monotherapy is conditionally recommended over biologic + MTX combination therapy. b May consider alternatives, if patient has primary TNFi biologic efficacy failure (IL 17i biologic, IL 12/23i biologic, abatacept, tofacitinib); has TNFi biologic-associated serious adverse event (IL 17i biologic, IL 12/23i biologic, abatacept, tofacitinib); patients have demonstrated partial response to the current TNFi biologic therapy, especially if the TNFi biologic is a monoclonal antibody (adding MTX); prefers an oral therapy tofacitinib); has severe psoriasis (IL17i); or patient prefers less frequent drug administration (IL 12/23i). c May consider alternatives (indicated in parentheses), if the patient has inflammatory bowel disease (IL 12/23i biologic, tofacitinib); prefers IV dosing (abatacept); has recurrent or serious infections (abatacept); prefers an oral therapy (tofacitinib); a history of recurrent candida infections (tofacitinib); or patient prefers less frequent drug administration (IL 12/23i). d May consider alternatives (indicated in parentheses), if patient prefers IV dosing (abatacept); has had recurrent or serious infections (abatacept); or prefers oral therapy (tofacitinib). e May consider the alternative, TNFi biologic monotherapy, if patient has demonstrated MTX-associated adverse events, prefers fewer medications or perceives MTX as a burden. f May consider the alternative, IL 17i biologic + MTX, if patient had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL 17i biologic was discussed as potentially beneficial to allow the new therapy time to work. g May consider the alternative, IL 12/23i biologic + MTX, if patient had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL 12/23i biologic was discussed as potentially beneficial to allow the new therapy time to work. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.
Enlarge  Figure 6-15: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment with IL-17i or IL-12/23i Biologic Monotherapy. <sup>a</sup> May consider alternatives (indicated in parentheses), if patient has contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (switching to IL 12/23i biologic, or switching to a different IL 17i biologic or adding MTX to the current regimen); if the patient had a secondary efficacy failure (initial response, but lack of response/efficacy with continued use) to the current IL 17i (different IL 17i biologic); severe psoriasis (different IL 17i biologic); if the patient had a partial response to the existing regimen (adding MTX to the current regimen); or prefers less frequent administrations (IL 12/23i biologic). <sup>b </sup>May consider alternatives (indicated in parentheses), if the patient had a secondary efficacy failure to current IL 17i (different IL 17i biologic); severe psoriasis (different IL 17i biologic); or if the patient had a partial response to the existing regimen (adding MTX to the current regimen). <sup>c </sup>May consider alternatives (indicated in parentheses), if the patient had contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (switching to IL 17i biologic or adding MTX to the current regimen); severe psoriasis not responding to the current therapy (switching to IL 17i biologic or adding MTX to the current regimen). <sup>d </sup>May consider adding MTX in patients with only partial response to the current therapy or in those who potentially have not had enough time to adequately responds. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. <em>Arthritis Rheumatol</em>. 2019;71(1):5-32.
Figure 6-15: ACR/NPF Recommendations for Treatment of Patients With Active PsA Despite Treatment with IL-17i or IL-12/23i Biologic Monotherapy. a May consider alternatives (indicated in parentheses), if patient has contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (switching to IL 12/23i biologic, or switching to a different IL 17i biologic or adding MTX to the current regimen); if the patient had a secondary efficacy failure (initial response, but lack of response/efficacy with continued use) to the current IL 17i (different IL 17i biologic); severe psoriasis (different IL 17i biologic); if the patient had a partial response to the existing regimen (adding MTX to the current regimen); or prefers less frequent administrations (IL 12/23i biologic). b May consider alternatives (indicated in parentheses), if the patient had a secondary efficacy failure to current IL 17i (different IL 17i biologic); severe psoriasis (different IL 17i biologic); or if the patient had a partial response to the existing regimen (adding MTX to the current regimen). c May consider alternatives (indicated in parentheses), if the patient had contraindications to TNFi biologic including recurrent infections, congestive heart failure, or demyelinating disease (switching to IL 17i biologic or adding MTX to the current regimen); severe psoriasis not responding to the current therapy (switching to IL 17i biologic or adding MTX to the current regimen). d May consider adding MTX in patients with only partial response to the current therapy or in those who potentially have not had enough time to adequately responds. The order of listing of various conditional recommendations or of different treatment choices within a conditional statement does not indicate any sequence in which treatment options would be chosen; each conditional statement stands on its own. Source: Singh JA, et al. Arthritis Rheumatol. 2019;71(1):5-32.

References

  • Ruderman EM, Gordon KB. Clinical Management of Psoriatic Arthritis and Psoriasis. 4th ed. Professional Communications Inc. 2022
  • Singh JA, Guyatt G, Ogdie A, et al. Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019;71(1):5-32.
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