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