Management of particular clinical situations in psoriatic arthritis: an expert’s recommendation document based on systematic literature review and extended Delphi process

Abstract

To establish practical recommendations for the management of patients with psoriatic arthritis (PsA) with particular clinical situations that might lead to doubts in the pharmacological decision-making. A group of six expert rheumatologists on PsA identified particular clinical situations in PsA. Then, a systematic literature review (SLR) was performed to analyse the efficacy and safety of csDMARDs, b/tsDMARDs in PsA. In a nominal group meeting, the results of the SLR were discussed and a set of recommendations were proposed for a Delphi process. A total of 65 rheumatologists were invited to participate in the Delphi. Agreement was defined if ≥ 70% of the participants voted ≥ 7 (from 1, totally disagree to 10, totally agree). For each recommendation, the level of evidence and grade of recommendation was established based on the Oxford Evidence-Based Medicine categorisation. Particular clinical situations included monoarthritis, axial disease, or non-musculoskeletal manifestations. The SLR finally comprised 131 articles. A total of 16 recommendations were generated, all but 1 reached consensus. According to them, it is crucial to carefully analyse the impact of individual manifestations on patients (disability, quality of life, etc.), but also to recognise the impact of each drug singularities on selected clinical phenotypes to adopt the most appropriate treatment strategy. Early diagnosis and treatment to target approach, along with a close risk management, is also necessary. These recommendations are intended to complement gaps in national and international guidelines by helping health professionals address and manage particular clinical situations in PsA.

Psoriatic Spondylitis: A Disease Manifestation in Debate

“…Of note, the task force of the EULAR recommendations for management of PsA does not recommend use of systemic glucocorticoids for axial disease, based on the 2016 update of the ASAS-EULAR management recommendations for axSpA 47,50 . On the other hand, a group of 6 Spanish expert rheumatologists on PsA recommend, based on systematic literature review and extended Delphi process, that “In patients with axial disease, oral or intramuscular short-term low-dose glucocorticoids (4–12 weeks) could be considered for axial symptoms” 51 …”

“…47,50 On the other hand, a group of 6 Spanish expert rheumatologists on PsA recommend, based on systematic literature review and extended Delphi process, that "In patients with axial disease, oral or intramuscular short-term low-dose glucocorticoids (4-12 weeks) could be considered for axial symptoms". 51 In recent years, an increasing number of target therapies have become available for the treatment of psoriasis PsA and axSpA, namely, biologic agents and small molecules, such as Janus kinase (JAK) inhibitors or the phosphodiesterase 4 inhibitor apremilast. A case report suggests that apremilast holds promise as a potential treatment for axial disease caused by PsA, and that it may delay radiographic progression in any accompanying sacroiliitis.…”

Tofacitinib combined with local low-dose ixekizumab injection benefits those with peripheral psoriatic arthritis

“…Treating psoriatic arthritis (PsA) is always difficult. Systemic treatments can be administered either orally or through intramuscular and intra-articular injection, including conventional synthetics, biologics and targeted synthetic disease-modifying antirheumatic drugs [ 1 ] . The alternatives, topical external therapies, are not effective on joint lesions due to drug permeability issues.…”