Article Text

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update
  1. Laure Gossec1,2,
  2. Xenofon Baraliakos3,
  3. Andreas Kerschbaumer4,
  4. Maarten de Wit5,
  5. Iain McInnes6,
  6. Maxime Dougados7,
  7. Jette Primdahl8,9,
  8. Dennis G McGonagle10,11,
  9. Daniel Aletaha12,
  10. Andra Balanescu13,
  11. Peter V Balint14,
  12. Heidi Bertheussen15,
  13. Wolf-Henning Boehncke16,
  14. Gerd R Burmester17,
  15. Juan D Canete18,
  16. Nemanja S Damjanov19,
  17. Tue Wenzel Kragstrup20,21,
  18. Tore K Kvien22,
  19. Robert B M Landewé23,24,
  20. Rik Jozef Urbain Lories25,26,
  21. Helena Marzo-Ortega10,11,
  22. Denis Poddubnyy27,28,
  23. Santiago Andres Rodrigues Manica29,30,
  24. Georg Schett31,
  25. Douglas J Veale32,
  26. Filip E Van den Bosch33,
  27. Désirée van der Heijde22,34,
  28. Josef S Smolen35,36
  1. 1 Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
  2. 2 APHP.Sorbonne Universite, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
  3. 3 Ruhr-Universität Bochum, Rheumazentrum Ruhrgebiet, Herne, Germany
  4. 4 Division of Rheumatology, Department of Medicine 3; 2nd Department of Medicine, Hietzing Hospital, Medical University of Vienna, Vienna, Austria
  5. 5 EULAR, Zurich, Switzerland
  6. 6 Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
  7. 7 Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
  8. 8 Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark
  9. 9 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
  10. 10 LTHT, Leeds NIHR Biomedical Research Centre, Leeds, UK
  11. 11 Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
  12. 12 Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  13. 13 Research Center of Rheumatic Diseases, Sf Maria Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
  14. 14 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
  15. 15 Patient Research Partner, EULAR, Oslo, Norway
  16. 16 Dermatology, University Hospitals of Geneva, Geneva, Switzerland
  17. 17 Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
  18. 18 Arthritis Unit, Department of Rheumatology and IDIBAPS, Hospital Clinic, Barcelona, Spain
  19. 19 Institute of Rheumatology, Belgrade University School of Medicine, Belgrade, Serbia
  20. 20 Department of Biomedicine, Aarhus University, Aarhus C, Denmark
  21. 21 Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark
  22. 22 Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  23. 23 Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands
  24. 24 Rheumatology, Zuyderland MC, Heerlen, The Netherlands
  25. 25 Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium
  26. 26 Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
  27. 27 Department of Rheumatology, Infectious Diseases and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
  28. 28 Epidemiology, German Rheumatism Research Center Berlin, Berlin, Germany
  29. 29 Rheumatology, Hospital de Egas Moniz, Lisboa, Portugal
  30. 30 Universidade Nova de Lisboa Centro de Estudos de Doencas Cronicas, Lisboa, Portugal
  31. 31 Internal Medicine, University of Erlangen-Nuremberg, Erlangen, Germany
  32. 32 Centre for Arthritis and Rheumatic Disease, Dublin Academic Medical Centre, St Vincent’s University Hospital, Dublin, Ireland
  33. 33 Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium
  34. 34 Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  35. 35 Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Wien, Austria
  36. 36 2nd Department of Medicine, Hietzing Hospital, Vienna, Wien, Austria
  1. Correspondence to Professor Laure Gossec, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris 75013, France; laure.gossec{at}


Objective To update the European League Against Rheumatism (EULAR) recommendations for the pharmacological treatment of psoriatic arthritis (PsA).

Methods According to the EULAR standardised operating procedures, a systematic literature review was followed by a consensus meeting to develop this update involving 28 international taskforce members in May 2019. Levels of evidence and strengths of recommendations were determined.

Results The updated recommendations comprise 6 overarching principles and 12 recommendations. The overarching principles address the nature of PsA and diversity of both musculoskeletal and non-musculoskeletal manifestations; the need for collaborative management and shared decision-making is highlighted. The recommendations provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs and local glucocorticoid injections are proposed as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis accompanied by factors such as dactylitis or joint damage, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumour necrosis factor (TNF), interleukin (IL)-17A or IL-12/23 should be initiated, taking into account skin involvement if relevant. If axial disease predominates, a TNF inhibitor or IL-17A inhibitor should be started as first-line disease-modifying antirheumatic drug. Use of Janus kinase inhibitors is addressed primarily after bDMARD failure. Phosphodiesterase-4 inhibition is proposed for patients in whom these other drugs are inappropriate, generally in the context of mild disease. Drug switches and tapering in sustained remission are addressed.

Conclusion These recommendations provide stakeholders with an updated consensus on the pharmacological management of PsA, based on a combination of evidence and expert opinion.

  • psoriatic arthritis
  • treatment
  • DMARDs (biologic)

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  • Handling editor David S Pisetsky

  • Twitter @KragstrupTW, @R_M_Santiago

  • Contributors All authors have contributed to this work and approved the final version.

  • Funding This study was funded by the European League Against Rheumatism. DMG and HM-O are supported by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (LBRC). The views expressed are those of the authors and not necessarily those of the (UK) National Health Service (NHS), the NIHR or the (UK) Department of Health.

  • Competing interests LG: AbbVie, Biogen, Celgene, Janssen, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB. XB: AbbVie, Amgen, BMS, Celgene, Chugai, Hexal, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Sandoz, UCB. AK: Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Merck Sharp and Dohme, Novartis, Pfizer. MdW: Through Stichting Tools from AbbVie, BMS, Celgene, Eli Lilly, Janssen-Cilag, Novartis, Pfizer, Roche. IM: AbbVie, BMS, Lilly, Novartis, Celgene, Gilead, Janssen, Boehringer, UCB, Pfizer. MD: AbbVie, BMS, Janssen, Lilly, Novartis, Merck, Pfizer, UCB. JP: BMS, Pfizer. DGM: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB. DA: AbbVie, Amgen, Gilead, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, Sobi. AB: AbbVie, Amgen, AstraZeneca, Angelini, AlfaSigma, BMS, Berlin-Chemie, Egis, Ewopharma, GSK, Lilly, Mylan, MSD, Novartis, Pfizer, Roche, Sandoz, Sanofi, Teva, UCB, Zentiva. PVB: AbbVie, Celgene, Lilly, MSD, Novartis, Pfizer, Richter. HB: Pfizer. W-HB: AbbVie, Almirall, BMS, Celgene, Leo, Lilly, Novartis, Pfizer, UCB. GRB: AbbVie, Celgene, Lilly, MSD, Novartis, Pfizer. JDC: Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, UCB. NSD: AbbVie, Boehringer Ingelheim, Gedeon Richter, Lilly, Novartis, Pfizer, Roche. TWK: Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer, UCB. TKK: AbbVie, Amgen, Biogen, BMS, Celltrion, Egis, Eli Lilly, Ewopharma, Hikma, Hospira/Pfizer, MSD, Mylan, Orion Pharma, Roche, Sandoz, Sanofi, UCB. RBML: AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB. RJUL is Director of Rheumatology Consultancy; AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB. HM-O: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB. DP: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. SARM: Janssen, MSD, Novartis. GS: AbbVie, BMS, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, UCB. DJV: AbbVie, Biogen, Boehringer Ingelheim, HealthBeacon, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. FEVdB: AbbVie, Celgene, Eli Lilly, Galapagos/Gilead, Janssen, Merck, Novartis, Pfizer, UCB. DvdH: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology. JSS: grants to institution from AbbVie, AstraZeneca, Janssen, Lilly, Merck Sharp & Dohme, Pfizer and Roche; speaker for AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO Pharma, Janssen, Lilly, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi and UCB.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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