EULAR advises 'cautious tapering' of DMARDs for patients with sustained PsA remission
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Rheumatologists may consider “cautious tapering” of DMARDs in patients with psoriatic arthritis who achieve sustained remission, according to a 2019 update to EULAR recommendations published in Annals of the Rheumatic Diseases.
“The European League Against Rheumatism (EULAR) developed recommendations for the pharmacological management of PsA in 2011 and updated them in 2015,” Laure Gossec, MD, PhD, of Sorbonne University in Paris, and colleagues wrote. “These recommendations had their main focus on the musculoskeletal aspects of the disease and addressed the entire spectrum of PsA severity since they pertained to patients with very mild to very severe PsA. In this rapidly evolving field, a further update of the 2015 recommendations became necessary to accommodate newly obtained evidence and insights.”
In an interview with Healio Rheumatology, Gossec noted that PsA is “one of the diseases where the treatment armamentarium is changing quickly.”
“Several new drugs are currently in development,” she said. “Furthermore, there is accrued data regarding efficacy but also safety of existing drugs. For this reason, EULAR decided an update was needed to the 2015 version of the recommendations.”
To update the EULAR recommendations for the pharmacological treatment of PsA, Gossec and colleagues formed a steering committee of five rheumatologists, a fellow, a patient research partner and a health professional. Together, they defined questions to be addressed in a systematic literature review, performed between October 2018 and May 2019, focusing on the years 2015-2018. The steering committee then met with a taskforce in May 2019 to form available data on disease management in PsA into practical recommendations.
The 28-member task force included 21 rheumatologists, two patients with PsA, one health professional, one dermatologist and three rheumatology fellows/trainees. Together, they represented 15 European countries. Members of the task force considered the results of the literature review, alongside the 2015 recommendations and proposals for changes made by the steering committee. Any changes or additions to the 2015 recommendations required a vote of at least 75% agreement among the task force. Any measure that failed to reach that threshold was amended and subjected to additional votes.
The task force ultimately drafted and approved six overarching principles and 12 recommendations. The overarching principles cover the nature of PsA and the diversity of musculoskeletal and non-musculoskeletal manifestations, as well as the need for collaborative management and shared decision-making. The recommendations provide treatment strategies for pharmacological therapies.
The recommendations include:
- Treatment should focus on achieving remission, or, alternatively, low disease activity, as a target, using regular assessment of disease activity and therapy adjustment.
- NSAIDs may be used for musculoskeletal signs and symptoms.
- Local glucocorticoid injections should be considered as adjunctive therapy, with systemic glucocorticoids used with caution and at the lowest effective dose.
- Conventional synthetic DMARDs should be started rapidly in patients with polyarthritis, with methotrexate preferred in those with skin involvement.
- Conventional synthetic DMARDs should also be considered in patients with mono-arthritis or oligo-arthritis, particularly with poor prognostic factors such as structural damage, high erythrocyte sedimentation rate/C-reactive protein, dactylitis or nail involvement.
- In patients with peripheral arthritis and an inadequate response to at least one conventional synthetic DMARD, therapy with a biological DMARD should be initiated, with an IL-17 or IL-12/23 inhibitor preferred when there is relevant skin involvement.
- A JAK inhibitor may be considered in patients with peripheral arthritis and an inadequate response to at least one conventional synthetic DMARD and at least one biological DMARD.
Additionally, a new recommendation states that “cautious tapering” of DMARDs may be considered among patients in sustained remission. The task force defined “sustained remission” as complete remission, rather than low disease activity, for at least 6 consecutive months.
“This new version of the recommendations integrates several important changes, including an increased place for non-TNF biologics, a new recommendation on the place of JAK inhibitors, which were not available in 2015, and a better-defined place for apremilast,” Gossec said. “[Also] the recommendations for the first time distinguish oligoarthritis from polyarthritis.”
“There is also a new recommendation regarding treatment tapering,” she added. “We hope clinicians will find these recommendations to be logical and to make sense, the step-up approach is consistent with what most of our colleagues are applying, we hope this will participate in improving the care of patients.”
Perspective
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Carlos M. Alonso, MD, FACR, RhMSUS
The available armamentarium to treat psoriatic arthritis has increased considerably over the last few years — treatment decisions have become even more complex than for rheumatoid arthritis. This is a good problem to have but one that presents multiple challenges.
Our understanding of the complexity of the disease has also improved and we can now make treatment decisions guided by the articular and non-articular clinical characteristics of the patient with the goal of achieving fast and effective disease control. The concept of treat-to-target is also valid and applicable to this disease. These updated guidelines incorporate these positions and viewpoints.
There are six main points from the EULAR 2019 update that we should focus on. First is the efficacy of methotrexate in a subgroup of patients with peripheral joint disease with or without skin involvement. This is an important fact, not only from the standpoint of safety, but also considering the cost of this drug as compared with newer agents. Second is the recognition of polyarticular disease as more aggressive, many times requiring earlier use of a biologic DMARD.
A third point to consider, based on recent clinical and research data, is that first line biologic treatment options should include IL-17 and IL-12/23 inhibitors, especially in patients with a high skin disease burden. Fourth, patients with persistent enthesitis benefit from early use of biologic DMARDs since the response to methotrexate is overall poor. Fifth, although data for the efficacy of apremilast is not as robust as for other agents, there is a group of patients that benefit from it and its early use should be considered in patients with certain comorbid conditions. Lastly, the concept of finding the smallest effective dose in patients who have achieved remission is important, as cost and safety are always major factors in treatment decisions.
Real-life care of patients with psoriatic arthritis involves not only treating the disease and its non-musculoskeletal manifestations, but also considering the presence of other comorbid conditions and treatment cost. These treatment guidelines provide a good framework that factors in updated research data and cost-effectiveness of drug options.
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