Differentiating oligoarthritis, polyarthritis marks 'big change' in EULAR guidelines for PsA
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The availability of new drug options and new definitions for polyarticular versus oligoarticular joint involvement in psoriatic arthritis were highlighted as the significant updates in the EULAR recommendations for the treatment of the disease, according to a presenter at the EULAR 2020 E-Congress.
“The treatment choices are very rich in PsA,” Laure Gossec, MD, PhD, associate professor of rheumatology, Pierre-and-Marie-Curie University and Pitié-Salpétrière Hospital, Paris, said in her presentation. “New drugs have been developed and come to market.”
The last version of the PsA recommendations, which was developed in 2015, proposed what Gossec called “a step-up approach” from NSAIDs, to methotrexate in peripheral forms of the disease, to a biologic DMARD, or possibly, a second conventional DMARD. At that point, switching of therapies may be considered. The current iteration largely adheres to that approach, albeit with consideration of novel classes such as JAK and phosphodiesterase type (PDE)-4 inhibitors now in the mix.
The 2019 document contains six over-arching principles and 12 recommendations. One over-arching principle has been added since 2015, along with two new recommendations.
Regarding the other unchanged principles, the first suggests that PsA is a heterogeneous disease that requires multidisciplinary treatment. The second highlights that shared decision-making between rheumatologist and patient is necessary. The third addresses the necessity of collaboration between rheumatologist and dermatologist. The fourth pertains to treating patients to quality of life (QOL) targets.
The fifth is the new principle. Gossec noted that this principle “insists on looking at each musculoskeletal manifestation” of PsA.
The sixth highlights management of non-musculoskeletal manifestations such as skin, eye and gastrointestinal tract comorbidities, along with traditional comorbidities such as metabolic syndrome, cardiovascular disease or depression.
Turning to the actual recommendations, the fifth, seventh and 12th points are all new.
In the fifth recommendation, it is suggested that a conventional synthetic DMARD should be considered in patients with monoarthritis or oligoarthritis, particularly those who demonstrate structural damage, high erythrocyte sedimentation rate/C reactive protein (CRP) levels, dactylitis or nail involvement. “We do have a big change regarding the way we deal with peripheral disease,” Gossec said. “In the new version, we clearly distinguish monoarthritis from oligoarthritis. Polyarticular disease is one of the most important prognostic factors of structural damage.”
The seventh stipulates that a JAK inhibitor may be considered in patients with peripheral arthritis who fail to adequately respond to at least one conventional synthetic DMARD and at least one biologic DMARD, or when a biologic DMARD is inappropriate.
“Cautious tapering” of DMARD therapy may be considered as part of the new 12th recommendation, despite just a small amount of data on the topic, according to Gossec. “The task force for 2020 thought tapering was important to discuss,” she said.
Looking at some of the smaller changes and updates from the 2015 to the 2020 documents, Gossec highlighted the use of conventional synthetic DMARDs like methotrexate in patients with relevant skin involvement. She said the decision was “not easy,” and added that, “the balance of efficacy, risk and safety was in favor of conventional synthetic DMARDs.”
Another change pertains to the choice of drugs after a conventional synthetic DMARD has failed. In the current document, a biologic DMARD may be used, along with an IL-17 or IL-12/23 inhibitor for patients with “relevant” skin involvement. “We prefer a drug that is more efficacious on skin as shown in psoriasis head-to-head trials,” she said. “Skin involvement is considered relevant if it is either extensive or has consequences on patient quality of life.”
Gossec also noted that recommendations for use of JAK and PDE-4 have also been modified in the current iteration of the document. JAK inhibitors may be used in patients with an inadequate response to at least one conventional synthetic DMARD. “We propose that [PDE-4 inhibition] may have efficacy in patients with mild disease,” she said.
“We believe the new version of the EULAR recommendations will propose a logical step up approach to the management of PsA,” Gossec concluded.
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Gossec L, et al. 2019 Update of the recommendations for the management of psoriatic arthritis with pharmacological therapies. Presented at: EULAR 2020 E-Congress; June 3-6, 2020 (virtual meeting).
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