Treatment recommendations
| Disease status | Treatment recommendation | Level of evidence* | Level of agreement†| Comments | |
| Peripheral arthritis | Mild | NSAIDs | A | 90.9% | For control of joint but not skin symptoms |
| NA | Intra-articular glucocorticoid injections | D | May be given judiciously to treat persistently inflamed joints, if care is taken to avoid injection through psoriatic plaques. Injections to any one joint should be repeated with caution according to clinical judgment | ||
| Moderate or severe | DMARDs (specific recommendations follow): | For all patients with severe or moderate peripheral arthritis. Consider for mild disease if patients do not respond to NSAIDS or intra-articular steroids. No evidence supporting DMARDs ahead of TNF inhibitors, although the effect size for TNF inhibitors is much larger than that for traditional DMARDs | |||
| SulfasalazineLeflunomideMethotrexateCiclosporine | AABB | ||||
| Moderate or severe | TNF inhibitors | A | For patients who fail to respond to at least one DMARD therapy. The three currently available TNF inhibitors (etanercept, infliximab and adalimumab) are equally effective for the treatment of peripheral arthritis and for the inhibition of radiographic progression. Patients with poor prognosis could be considered for TNF inhibitors even if they have not failed a standard DMARD | ||
| Skin disease | Moderate to severe | Phototherapy | A | 69.2% | First-line therapies:Phototherapy includes UVB/nbUVB, oral PUVA, bath PUVA, with or without acitretin. An initial trial of phototherapy should be made, unless it is not appropriate or if psoriasis is in areas that preclude phototherapy (ie, scalp, groin, axilla). All forms of phototherapy are considered as a group, although many consider that PUVA therapy carries increased risk of skin cancer compared with other UV modalities. Aggressive immunosuppression should not follow extensive phototherapy (especially PUVA), given the increased risk of melanoma and non-melanoma skin cancer in this scenario |
| Methotrexate | A | ||||
| Fumaric acid esters | A | ||||
| TNF inhibitors | A | TNF inhibitors include etanercept, adalimumab and infliximab | |||
| Efalizumab | A | ||||
| Ciclosporine | A | Ciclosporine should be limited to less than 12 consecutive months because cumulative toxicity (ie, multiple courses) is not well studied | |||
| Acitretin | A | Second-line therapies | |||
| Alefacept | A | ||||
| Sulfasalazine | A | Third-line therapies | |||
| Hydroxyurea | C | ||||
| Leflunomide | A | ||||
| Mycophenolate mofetil | C | ||||
| Thioguanine | C | ||||
| Nail disease | NA | Retinoids | C | 69.2% | |
| Oral PUVA | C | ||||
| Ciclosporine | C | ||||
| TNF inhibitors | C | TNF inhibitors include infliximab and alefacept | |||
| Spinal disease | Mild to moderate | NSAIDs | A | 86.4% | For patients who fail therapies for mild to moderate disease |
| Physiotherapy | A | ||||
| Education, analgesia and injection of sacroiliac joint | A | ||||
| Moderate to severe | TNF inhibitors | A | Infliximab, etanercept and adalimumab have all demonstrated efficacy in AS; the consensus was that similar treatment responses reported in AS were also likely to be observed in axial PsA | ||
| Enthesitis | Mild | NSAIDS, physical therapy, corticosteroids | D | 87.9% | |
| Moderate | DMARDs | D | |||
| Severe | TNF inhibitors | A | Evidence has been demonstrated for infliximab or for etanercept (in spondyloarthropathies) | ||
| Dactylitis | NA | NSAIDs | D | 90.2% | Usually employed initially |
| NA | Corticosteroids | D | Many clinicians rapidly progress to injected steroids | ||
| Resistant | DMARDs | D | Nearly always in the context of co-existing active disease | ||
| NA | Infliximab | A | Some evidence available |
*See Methods section of manuscript for description of categories and levels of evidence.
†Percentage of survey responders who agreed or strongly agreed (see supplementary material).
AS, ankylosing spondylitis; DMARD, disease-modifying antirheumatic drug; NA, not applicable or not specifically defined; NSAID, non-steroidal anti-inflammatory drug; PsA, psoriatic arthritis; PUVA, psoralen–ultraviolet light; TNF, tumour necrosis factor; UVB, ultraviolet B light.