EULAR removes systemic glucocorticoid use from psoriatic arthritis recommendations
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EULAR has removed the use of systemic glucocorticoids from its recommendations for the management of psoriatic arthritis, according to a presentation at the EULAR 2023 Congress.
“We no longer have put into the recommendation the use of systemic glucocorticoids,” Laure Gossec, MD, PhD, a professor of rheumatology at Pitié-Salpêtrière University Hospital and Sorbonne University, in Paris, told attendees. “We have always had reservations about its use and now we have taken it out of the recommendation.”
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The altered recommendations are part of a 2023 update presented at the EULAR annual congress. The recommendations for PsA were last revised in 2019.
“When we performed the last update of the recommendations in 2019, we were already very happy to have several modes of action available in psoriatic arthritis,” Gossec said.
She additionally noted the approvals and expanded use of several therapeutics — including conventional synthetic disease-modifying antirheumatic drugs, TNF inhibitors, interleukin-12, IL-12/23p19 and IL-17 a and f inhibitors, abatacept (Orencia, Bristol Myers Squibb) and Janus kinase inhibitors — in PsA since that time.
“Since 2019, the field of PsA has moved forward at a great pace,” Gossec said.
Specifically, the approvals of IL-23 inhibitors guselkumab (Tremfya, Janssen) and risankizumab (Skyrizi, Abbvie), along with the JAK inhibitor upadacitinib (Rinvoq, Abbvie) prompted the EULAR PsA task force to reconvene to update the document, she added.
“We now have new drugs available to us,” Gossec said.
The guideline development process followed standard operating procedures for all EULAR recommendations, including a literature review, task force meetings and voting processes. Ultimately, 38 publications on medication efficacy, and 24 on safety, were factored into the deliberations.
Among the changes the task force made was an increase in the number of over-arching principles, from six to seven.
The additional seventh principle states that the choice of treatment should take account of safety considerations regarding individual modes of action to improve the benefit-risk profile, Gossec said.
In addition, there are now just 11 recommendations, rather than 12 from the previous iteration.
“Keep in mind, the recommendations are for pharmacological, non-topical treatments only,” Gossec said. “Their main focus is on musculoskeletal manifestations, aiming for a balance between efficacy and safety.”
The first recommendation remains unchanged from 2019. However, a “big change” in the second recommendation removed the use of systemic glucocorticoids.
In addition, NSAIDs should only be used in specific patient populations, according to the 2023 document.
Another change pertains to stepping up from a conventional synthetic DMARD to a biologic. Clinicians may continue to sequence a TNF, IL-17a, IL-12/23p19, IL-17f or JAK inhibitor based on the patient’s individual profile, according to Gossec.
“We have not proposed an order for these drugs,” she said. “Why is this? Because we do not have the data.”
Meanwhile, the fifth recommendation on JAK inhibitors has been slightly modified to highlight its use in peripheral arthritis after another biologic, or when other biologics are not appropriate.
Another change pertains to axial disease. After NSAIDs, an IL-17a inhibitor should be used first before moving to other biologic modes of action.
The ninth recommendation is an “entirely new” look at non-musculoskeletal manifestations like skin disease or inflammatory bowel disease, Gossec said. In short, an IL-17a or f inhibitor, or an IL-12/23 inhibitor, may be preferable to TNF or JAK inhibition for skin disease.
“You should look at non-musculoskeletal manifestations when [choosing] a mode of action,” Gossec said. “Refer to the [European Medicines Agency] recommendations for inflammatory bowel disease.”
Regarding the final recommendation, Gossec noted that clinicians should be “cautious” when tapering drugs in patients in sustained remission.
“We now have a wealth of drugs for PsA,” she concluded. “We also have more safety data and more efficacy data. A big focus on safety has been placed on these recommendations.”
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Gossec L. EULAR-Recommendations on the management of PsA. Presented at: EULAR 2023 Congress; May 31 to June 3, 2023, Milan, Italy.
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