New EULAR recommendations for psoriatic arthritis urge biologics after methotrexate failure
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Key takeaways:
- EULAR recommendations on pharmacological PsA management cover all available drugs in a “practical and progressive approach.”
- Recommendations should aid clinicians and advocacy for improved access.
Rheumatologists should turn to biologics as usual treatment in patients with psoriatic arthritis who demonstrate an inadequate response to methotrexate, according to new EULAR recommendations.
The updated recommendations “are a big step forward compared with the previous ones,” lead author Laure Gossec, MD, PhD, of Sorbonne University, in Paris, told Healio. They take into account new data on all drugs available for PsA, and feature a “smaller role” for steroids and NSAIDs, as well as “a place” for JAK inhibitors and apremilast (Otezla, Amgen), she added.
“Since the last EULAR recommendations for the pharmacological management of PsA in 2019, the field has changed significantly,” Gossec and colleagues wrote in Annals of the Rheumatic Diseases. “This update addresses the non-topical, pharmacological management of PsA, with a specific focus on musculoskeletal manifestations, while also addressing the spectrum of PsA, including how skin psoriasis, extra-musculoskeletal manifestations and comorbidities should influence treatment choices.”
A task force of 37 experts from 19 countries convened in April 2023 to form the updated recommendations. The process included a systemic literature review followed by discussions in small groups and plenary sessions until consensus was reached on each bullet point.
Their work resulted in most of the 2019 recommendations being “modified substantially,” Gossec and colleagues wrote. A new overarching principle states that treatment choice should involve “safety considerations regarding individual modes of action to optimize the benefit-risk profile.” Also, a new recommendation advises that the mode of action should be chosen in relation to the non-musculoskeletal manifestations. For example, an anti-TNF monoclonal antibody should be given preference where there is uveitis.
The seven overarching principles are:
- PsA is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment.
- Treatment should aim at the best care and must be based on a shared decision making between the patient and the rheumatologist, considering efficacy, safety, patient preferences and costs.
- Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with PsA. In the presence of clinically relevant skin involvement, a rheumatologist and a dermatologist should collaborate in diagnosis and management.
- The primary goal of treatment is to maximize health-related quality of life through control of symptoms, prevention of structural damage, normalization of function and social participation. Alleviating inflammation is an important component to achieve these goals.
- Consideration should be given to each musculoskeletal manifestation, with treatment decisions made accordingly.
- Non-musculoskeletal manifestations — particularly in the skin, eye and gastrointestinal tract — should be taken into account. Comorbidities such as obesity, metabolic syndrome, cardiovascular disease or depression should also be considered.
- The choice of treatment should take account safety considerations regarding individual modes of action to optimize the benefit-risk profile.
The updated 11 recommendations include:
- Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate therapy adjustment.
- NSAIDs may be used to relieve musculoskeletal signs and symptoms, with local injections of glucocorticoids considered as adjunctive therapy.
- In patients with polyarthritis or monoarthritis/oligoarthritis and poor prognostic factors — such as structural damage, elevated acute phase reactants, dactylitis or nail involvement — a conventional synthetic DMARD should be initiated rapidly, with methotrexate preferred in those with clinically relevant skin involvement.
- In patients with peripheral arthritis and an inadequate response to at least one conventional synthetic DMARD, therapy with a biologic DMARD should be commenced.
- In patients with peripheral arthritis and an inadequate response to at least one biologic DMARD, or when one is not appropriate, a JAK inhibitor may be considered with safety considerations taken into account.
Other recommendations include the use of a PDE4 inhibitor in patients with mild disease and an inadequate response to at least one conventional synthetic DMARD, in whom neither a biologic DMARD nor a JAK inhibitor is appropriate. In patients with unequivocal enthesitis and an insufficient response to NSAIDs or local glucocorticoid injections, therapy with a biologic DMARD should be considered. In patients with clinically relevant axial disease with an insufficient response to NSAIDs, an interleukin (IL)-17A inhibitor, a TNF inhibitor, an IL-17 A/F inhibitor or a JAK inhibitor should be considered.
According to the task force, the chosen mode of action should reflect non-musculoskeletal manifestations. In cases with clinically relevant skin involvement, preference should be given to an IL-17A or IL-17A/F or IL-23 or IL-12/23 inhibitor. Meanwhile, in uveitis, preference should be given to an anti-TNF monoclonal antibody, whereas with IBD the preference should be for anti-TNF monoclonal antibody, an IL-23 inhibitor, an IL-12/23 inhibitor or a JAK inhibitor.
In patients with an inadequate response or intolerance to a biologic DMARD or a JAK inhibitor, switching to another biologic DMARD or JAK inhibitor should be considered, including one switch within a class. Lastly, in patients with sustained remission, tapering of DMARDs may be considered.
“The main points are a smaller role for steroids and NSAIDs, keeping methotrexate/conventional synthetic DMARDs as first-line DMARDs, putting all biologics at the same level but indicating some drugs be put forward in cases of relevant skin involvement or extra musculoskeletal manifestations, and a place for JAK inhibitors and apremilast, which takes into account the efficacy safety balance,” Gossec said.
The researchers concluded that the updated principles and recommendations should aid the management of individual patients and “advocacy for better access to care and for research.”
“The updated 2023 recommendations should be helpful to clinicians but also to health professionals and patients when discussing treatment options,” they added. “They can also be helpful to promote access to optimal care.”
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