Researchers Explore Similarities, Differences in Guidelines for PsA Treatment

In the last 2 years, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the European Alliance of Associations for Rheumatology (EULAR) have updated their recommendations to integrate guidance for new treatment options.

As treatment guidelines are constantly being updated to account for new treatment options for psoriatic arthritis (PsA), researchers of a new study in Joint Bone Spine have outlined recommendations by 2 organizations.

In the last 2 years, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the European Alliance of Associations for Rheumatology (EULAR) have updated their recommendations to integrate guidance for new treatment options. Treatments included in the recommendations are traditional disease modifying antirheumatic drugs (csDMARDs), such as methotrexate, as well as targeted therapies, such as biologics (bDMARDs) and targeted synthetic drugs (tsDMARDs).

“Regular updates to treatment recommendations are driven by the ongoing expansion in therapeutic options and research, which means that recommendations become outdated relatively quickly,” wrote the researchers. “The latest updates of the EULAR and GRAPPA treatment recommendations still differ somewhat in scope and output but show more similarities than differences as they are both underpinned by the same evidence-based approach. The implementation of these recommendations should benefit patients with PsA.”

Both groups include recommendations for bDMARDs that target interleukin-23 by inhibiting the p19 subunit. GRAPPA also includes recommendations for use of guselkumab and risankizumab in peripheral arthritis, enthesitis, and dactylitis based on additional data accounted for in their guidelines. The researchers noted that controversy remains around the efficacy of these treatments in axial disease.

Some differences in the recommendations are driven by the years of data included. EULAR included data from 2015 through 2018 and GRAPPA included data through 2020. For example, both guidelines recommend methotrexate for peripheral arthritis, although GRAPPA also recommends the treatment for enthesitis and dactylitis due to the inclusion of the SEAM-PsA 2019 study—a key difference between the 2 guidelines.

Similarly, at the time of EULAR recommendations, tofacitinib, used in combination with methotrexate, was the sole Janus kinase (JAK) inhibitor. Due to the limited data available on their safety, JAK inhibitors were recommended for second-line treatment. In their recommendations, GRAPPA includes JAK inhibitors in several domains of PsA, often at the same level as bDMARDS. These recommendations by GRAPPA represent more data on JAK inhibitors that have emerged since the EULAR recommendation literature review period, including the addition of upadacitinib.

The researchers flagged safety considerations for JAK inhibitors not accounted for in either guidelines due to data emerging after the literature review periods. Data from the ORAL-Surveillance study showed tofacitinib failed to meet the primary end point of noninferiority for cardiovascular risk and malignancy compared with TNF-α inhibitors in patients with rheumatoid arthritis. The group noted the need for further research in patients with PsA to identify which patients are most appropriate for JAK inhibitor therapy.

“There is very limited evidence in the literature to support the order in which medications should be used. This introduces more variability into the recommendations, as different factors influence recommendations on this point. In GRAPPA, csDMARDs, bDMARDs, and tsDMARDs are recommended equally without any clear order where there is evidence for their efficacy,” explained the researchers. “As GRAPPA is an international organization, all drugs were recommended given the limited amount of comparative evidence and to allow physicians to make appropriate choices depending on their health care settings.”

The GRAPPA recommendations, explained the researchers, focuses on being less prescriptive compared with the EULAR recommendations, which offers guidance for providers choosing a treatment and includes a clear “step-up” approach for treatment. The EULAR guidelines recommended at least 1 csDMARD—typically methotrexate—be used before bDMARDS or tsDMARDS for peripheral arthritis.


Coates L, Gossec L. The updated GRAPPA and EULAR recommendations for the management of psoriatic arthritis: similarities and differences. Joint Bone Spine. Published online September 29, 2022. doi:10.1016/j.jbspin.2022.105469

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