ACR and NPF Unveil New Clinical Guideline for Treating Psoriatic Arthritis

Kelly Davio

On Tuesday afternoon at The American College of Rheumatology’s (ACR) 2017 Annual Meeting, ACR and the National Psoriasis Foundation (NPF) presented a draft of their new, jointly developed clinical guideline for treating psoriatic arthritis (PsA).

Development of the Guideline
Alexis Ogdie, MD, MSCE, addressed the method of developing the new approach to treating PsA, explaining that the ACR and NPF teams evaluated treatments including non-pharmacologic therapies (such as smoking cessation, weight loss, and exercise); symptomatic treatments (including non-steroidal anti-inflammatory drugs [NSAIDs], glucocorticoids, and local glucocorticoid injections); oral small molecule drugs (OSM, a term synonymous with, but preferred by the panel to, disease-modifying anti-rheumatic drugs [DMARDs]); tumor necrosis factor (TNF) inhibitors; IL-12 and IL-23 inhibitors; IL-17 inhibitors; abatacept; and tofacitinib.

Ogdie explained that ACR and NPF began by evaluating PICO questions (which consider the patient, intervention, comparison intervention, and outcome), investigating the level of evidence available to address each of the PICO questions, and making a recommendation that was either strong (based on good evidence) or conditional (based on a lower threshold of evidence). Strong recommendations are those that more than 50% of patients should adopt, and that could be adopted by policymakers in most situations.

A patient panel meeting in April 2017, which included 10 patients, addressed patient considerations in selecting a therapy, with patients listing treatment burden, onset of action, side effects, and effectiveness, among others, and key concerns.

Finally, a voting panel—comprising 2 patients, 11 rheumatologists, 1 rheumatology physician assistant, 1 dermatologist, and 1 dermatologist/rheumatologist—adopted recommendations that achieved a 70% or greater consensus.

Recommendations for Treatment
Jasvinder Singh, MD, MBBS, MPH, presented a sample of the 80 treatment recommendations established in the new guideline, noting that the 94% of the recommendations are conditional while 6% are strong. Among the example recommendations that Singh discussed are the following: Treat-to-Target and Vaccination
The new guideline recommends a treat-to-target strategy, and recommends that patients initiate biologic treatment and then receive killed vaccines (rather than delaying treatment until after killed vaccines have been administered). It also recommends delaying the start of a biologic if the patient requires a live, attenuated vaccination.

Non-Pharmacological Treatments
The guideline gives a strong recommendation, with a high level of evidence, to smoking cessation in patients with PsA. Conditional recommendations include exercise (with low-impact exercise, such as Tai Chi, yoga, or swimming, noted as being preferable to high-impact exercise); physical therapy; occupational therapy; weight loss in the case of patients who are overweight or obese; massage therapy; and acupuncture.

Future Research and Added Guidelines
Singh pointed out that many common clinical situations in the treatment of PsA lack strong evidence in the medical literature. This lack of evidence suggests a need for greater investigation into the following areas: Singh also pointed out room for improvement in the guideline, and specified the following as topics that the guideline could address in future revisions: The group hopes to publish the guideline in a peer-reviewed journal and disseminate the document to the medical community shortly. ACR and NPF will continue to provide periodic literature search updates and annual reevaluations to the guideline.
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