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ACR, National Psoriasis Foundation stress treat-to-target, TNF inhibitors in PsA guidelines
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Physicians should use a treat-to-target approach, as well as TNF inhibitor biologics as a first-line therapy, in all patients with active psoriatic arthritis, according to new treatment guidelines developed by the American College of Rheumatology and the National Psoriasis Foundation.
“Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” Jasvinder Singh, MD, MPH, of the University of Alabama at Birmingham, the principal investigator, said in a press release. “The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation.”
Published simultaneously in Arthritis Care & Research, Arthritis & Rheumatology and the Journal of Psoriasis and Psoriatic Arthritis, the treatment guidelines also urge smoking avoidance and cessation, and include recommendations for nonpharmacologic treatments, vaccinations, psoriatic spondylitis and predominant enthesitis, as well as treatment in the presence of inflammatory bowel disease, diabetes or serious infections.
To develop the guidelines under a collaboration of the ACR and National Psoriasis Foundation, investigators worked in four teams, selected by the ACR Quality of Care Committee, including:
- A core leadership team, which coordinated the project;
- A literature review team, which performed a literature search;
- An expert panel, made up of patients, patient advocates, rheumatologists, dermatologists, one dermatologist-rheumatologist and one rheumatology nurse practitioner, which developed clinical questions; and
- A voting panel, which included rheumatologists, one dermatologist, one dermatologist-rheumatologist, one rheumatology physician assistant and two patients, one of whom was also a physical therapist.
Additionally, a nine-member patient panel, made up of adults with PsA, reviewed the accumulated evidence and provided input on their own preferences and values.
The investigators used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides rigorous standards for judging literature quality, and assigns strengths to each recommendation based on the weight of the available evidence. The voting panel achieved consensus on both the direction and the strength of the recommendations.
The final guidelines include dozens of recommendations on the management of active PsA, both in patients who are treatment-naive and those who continue to demonstrate active PsA despite receiving therapy. In particular, the guidelines addresse the use of oral small molecules, TNF inhibitors, interleukin-12/23 inhibitors, IL-17 inhibitors, abatacept and tofacitinib.
“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNF inhibitor biologic first,” Dafna Gladman, MD, of the University of Toronto, a member of the National Psoriasis Foundation Medical Board and the project’s core leadership team, said in the release. “This doesn’t hold true once other symptoms and comorbidities are present, so oral small molecules can continue to be a first-line option for patients that have contraindications to TNF inhibitor treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy.”
Gladman added, “Providers should take into consideration all active disease domains, comorbidities, and the patient’s functional status when choosing the optimal therapy for an individual at a given point in time.”
Regarding nonpharmacologic therapies, the guidelines recommend exercise over no exercise, although the investigators favored low-impact activities — such as tai chi, yoga or swimming — rather than high-impact exercise.
Due to limited data in some areas, the quality of evidence was often graded low or very low, the investigators wrote. This low quality of evidence led the investigators to categorize 94% of their recommendations as “conditional.” The remaining 6% of the recommendations are “strong.”
“Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions,” Singh said in the release. “This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naive, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations.” – by Jason Laday
References:
Singh JA, et al. Arthritis Care Res. 2018;doi:10.1002/acr.23789.
Singh JA, et al. Arthritis Rheumatol. 2018;doi:10.1002/art.40726.
Singh JA, et al. J Psoriasis Psoriatic Arthritis. 2018;doi:10.1177/2475530318812244.
Disclosure: Singh reports consulting fees — in amounts of less than $10,000 each — from Allergan Pharmaceuticals, Bioiberica, Crealta/Horizon, Fidia Pharmaceuticals, Iroko, Medscape, Merz, Regeneron, Savient, Takeda, UBM and WebMD, as well as research support from Savient Pharmaceuticals and Takeda. Gladman reports consulting fees, speaking fees, and/or honoraria from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB — all in amounts of less than $10,000 each. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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W. Benjamin Nowell, PhD
The newly published clinical practice guideline for the treatment of psoriatic arthritis developed by the ACR in collaboration with the National Psoriasis Foundation has the potential to help patients living with PsA access needed medications with fewer barriers. Previously, rheumatologists in the United States have been turning to existing PsA clinical practice guidelines, such as those developed by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and EULAR.
The new ACR guideline stands out because of the enhanced transparency and rigor of the development process and its implications for patient care and access. In developing guidelines, the ACR uses the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which relies on evidenced-based recommendations and is considered the international standard in guideline development.
Alongside scientific and clinical experts, the ACR and NPF convened patients living with PsA and representatives of patient organizations on both their expert and voting panels to ensure that the patient perspective was represented. Several conditional recommendations will likely help patients achieve greater access to available treatment options for managing their disease in consultation with their rheumatologist.
- The panel voted for a conditional recommendation to use a treat-to-target approach for all patients with active PsA. From a patient perspective, this is preferable to a strong recommendation because it provides more nuance to implement treat-to-target, which often entails more aggressive treatment and can raise patient concerns about side effects or additional medication costs.
- TNF inhibitor biologics as a first-line therapy option in patients were given a conditional recommendation, which will hopefully help patients access more targeted and effective medications more quickly. In the past, patients have had to first start with oral small-molecule treatments, like methotrexate. This recommendation could improve access since the new ACR guideline will serve as rationale for TNF inhibitors as a first-line therapy in the event a health plan denies a claim.
- The clinical practice guideline expands the definition of severe disease beyond physician-derived clinical indicators to include patient quality of life markers such as their ability to work and function in their daily life.
CreakyJoints supports the ACR evidenced-based clinical practice guideline for PsA because they are based primarily on evidence from systematic reviews of research with input from practicing physicians as well as PsA patient communities to keep patients’ experience of disease in the foreground. It is important that each patient with arthritis be treated as an individual, taking into account their treatment goals and preferences — the new ACR guideline for PsA facilitates this approach.
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