EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

Abstract

ObjectiveNew modes of action and more data on the efficacy and safety of existing drugs in psoriatic arthritis (PsA) required an update of the EULAR 2019 recommendations for the pharmacological treatment of PsA.MethodsFollowing EULAR standardised operating procedures, the process included a systematic literature review and a consensus meeting of 36 international experts in April 2023. Levels of evidence and grades of recommendations were determined.ResultsThe updated recommendations comprise 7 overarching principles and 11 recommendations, and provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs should be used in monotherapy only for mild PsA and in the short term; oral glucocorticoids are not recommended. In patients with peripheral arthritis, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended and methotrexate preferred. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drug (bDMARD) should be initiated, without preference among modes of action. Relevant skin psoriasis should orient towards bDMARDs targeting interleukin (IL)-23p40, IL-23p19, IL-17A and IL-17A/F inhibitors. In case of predominant axial or entheseal disease, an algorithm is also proposed. Use of Janus kinase inhibitors is proposed primarily after bDMARD failure, taking relevant risk factors into account, or in case bDMARDs are not an appropriate choice. Inflammatory bowel disease and uveitis, if present, should influence drug choices, with monoclonal tumour necrosis factor inhibitors proposed. Drug switches and tapering in sustained remission are also addressed.ConclusionThese updated recommendations integrate all currently available drugs in a practical and progressive approach, which will be helpful in the pharmacological management of PsA.

Early psoriatic arthritis: when is the right time to start advanced therapy?

“…40 This has been reflected in clinical recommendations suggesting consideration of b/tsDMARD therapy after failure of at least one csDMARD in oligoarthritis or insufficient response to non-steroidal anti-inflammatory drugs (NSAIDs) or local glucocorticoid injections in enthesitis. 41 Furthermore, unlike the earlier clinical trials of TNFis, clinical trials of newer bDMARDs are more diverse in sex and race and generally include patients with shorter disease duration, lower swollen and tender joint counts (SJC and TJC) and C-reactive protein (CRP) levels at baseline. This is due, in part, to increasing awareness of the condition and earlier diagnosis, as well as advances in the availability and sensitivity of imaging such as ultrasound and Magnetic Resonance Imaging (MRI) that enable earlier detection of subclinical disease activity.…”

“…Furthermore, the longevity of response and the possibility of whether or not early treatment might enable long-term remission with the withdrawal of bDMARD therapy remains uncertain, and the current European League Against Rheumatism (EULAR) and Group for Research and Assessement of Psoriasis and Psoriatic Arthritis (GRAPPA) recommendations advise caution with drug tapering/withdrawal even in patients who achieve early and sustained responses. 41 , 57 …”

Ultrasonographic Synovitis Is Associated with the Development of Joint Destruction in Patients with Psoriatic Arthritis

“…PsA is usually treated according to the recommendations of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) or the European League Against Rheumatism (EULAR) [ 5 , 6 ]. In these recommendations, treatment should be enhanced according to the disease activity in the skin, entheses, joints, etc.…”

No difference in clinical parameters and drug retention in PsA patients receiving b/tsDMARD monotherapy versus combination with methotrexate: data from the RABBIT-SpA registry

“…Both the EULAR and GRAPPA recommendations still place csDMARDs as common first-line DMARD therapy, the recent EULAR recommendations favouring the immediate start with csDMARDs especially in patients with polyarthritis or those with monarthritis/oligoarthritis and poor prognostic factors. 9 As bDMARDs and tsDMARDs have shown superiority to csDMARDs, regular assessment of clinical response and early escalation of therapy are advised in both recommendations.…”

“…The EULAR recommendations favour to continue combination therapy with a csDMARD versus monotherapy and to continue MTX with a bDMARD in patients already taking this drug and tolerating it well. 9 In contrast, GRAPPA concludes that a combination of csDMARDs with bDMARDs might not be necessary to achieve short-term response. 8 However, both recommendations conclude that the potential benefit of concomitant therapy with csDMARDs with all bDMARDs is incompletely defined.…”