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
- In the case of treatment-naïve active PsA, the guideline recommends starting a TNF inhibitor (instead of an OSM, IL-17 inhibitor, IL-12 inhibitor, or IL-23 inhibitor). An OSM is preferable to other biologics if a TNF inhibitor is not an option. Methotrexate is preferable to NSAIDs, and an IL-17 inhibitor is preferable to an IL-12 or IL-23 inhibitor. This recommendation is conditional and should be discussed with the patient.
- Patients with active PsA despite OSM therapy should be switched to a TNF inhibitor rather than to another OSM or any other type of biologic. If PsA is still active after the change, an IL-17 inhibitor should be the next step, rather than an OSM or other biologic. Finally, if PsA continues to be active, the patient should be switched to an IL-12 or IL-23 inhibitor rather than an OSM, abatacept, or tofacitinib. This recommendation is also conditional and should evaluated in light of patient preferences.
- A patient who has active PsA spondylitis and axial disease despite treatment with NSAIDs should be switched to a TNF inhibitor rather than to another biologic. If the PsA remains active, the patient should then be switched to an IL-17 biologic (rather than an IL-12 or IL-23 inhibitor). Again, this conditional recommendation should be discussed with the patient.
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.
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:
- Head-to-head comparisons of treatments for PsA
- Specific studies devoted to enthesitis, axial disease, and arthritis multilans
- Randomized trials of non-pharmacological interventions
- Trials of monotherapy versus combination therapy
- Vaccination trials for live, attenuated vaccines
- Trials and registry studies of patients with common comorbidities
- Studies of NSAIDs and glucocorticoids to define their role in PsA management
Singh also pointed out room for improvement in the guideline, and specified the following as topics that the guideline could address in future revisions:
- Treatment options for patients for whom a biologic is not a viable treatment option
- Use of PsA therapies in pregnancy
- Incorporation of high-quality cost or cost-effectiveness analyses into recommendations
- Other comorbidities, such as fibromyalgia, hepatitis, depression and anxiety, malignancy, and cardiovascular disease
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.