EULAR recommendations for the management of PsA, with levels of evidence, grade of recommendations and level of agreement
| Overarching principles | Level of agreement (mean±SD) | |
|---|---|---|
| A. | Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment. | 9.8±0.5 |
| B. | Treatment of psoriatic arthritis patients should aim at the best care and must be based on a shared decision between the patient and the rheumatologist. | 9.8±0.8 |
| C. | Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with psoriatic arthritis; in the presence of clinically significant skin involvement a rheumatologist and a dermatologist should collaborate in diagnosis and management. | 9.6±0.8 |
| D. | The primary goal of treating patients with psoriatic arthritis is to maximise long-term health-related quality of life, through control of symptoms, prevention of structural damage, normalisation of function and social participation; abrogation of inflammation, targeted at remission, is an important component to achieve these goals. | 9.7±0.6 |
| E. | Patients should be regularly monitored and treatment should be adjusted appropriately. | 9.7±0.7 |
| Recommendations | Level of evidence | Grade of recommendation | Level of agreement (mean±SD) | |
|---|---|---|---|---|
| 1. | In patients with psoriatic arthritis, non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms. | 1b | A | 9.4±0.9 |
| 2. | In patients with active disease (particularly those with many swollen joints, structural damage in the presence of inflammation, high ESR/CRP and/or clinically relevant extraarticular manifestations), treatment with disease-modifying drugs, such as methotrexate, sulfasalazine, leflunomide, should be considered at an early stage. | *1b, †4 | B | 9.4±0.7 |
| 3. | In patients with active psoriatic arthritis and clinically relevant psoriasis, a disease-modifying drug that also improves psoriasis, such as methotrexate, should be preferred. | 1b | A | 9.1±1.0 |
| 4. | Local injections of corticosteroids should be considered as adjunctive therapy in psoriatic arthritis; systemic steroids at the lowest effective dose may be used with caution. | ‡3b, §4 | C | 8.9±1.2 |
| 5. | In patients with active arthritis and an inadequate response to at least one synthetic disease-modifying antirheumatic drug, such as methotrexate, therapy with a tumour necrosis factor inhibitor should be commenced. | 1b | B | 8.9±1.5 |
| 6. | In patients with active enthesitis and/or dactylitis and insufficient response to non-steroidal anti-inflammatory drugs or local steroid injections, tumour necrosis factor inhibitors may be considered. | 1b | B | 8.5±1.5 |
| 7. | In patients with predominantly axial disease that is active and has insufficient response to non-steroidal anti-inflammatory drugs, tumour necrosis factor inhibitors should be considered. | 2b | C | 9.3±0.9 |
| 8. | Tumour necrosis factor inhibitor therapy might exceptionally be considered for a very active patient naive of disease-modifying treatment (particularly those with many swollen joints, structural damage in the presence of inflammation, and/or clinically relevant extra-articular manifestations, especially extensive skin involvement). | 4 | D | 8.6±1.7 |
| 9. | In patients who fail to respond adequately to one tumour necrosis factor inhibitor, switching to another tumour necrosis factor inhibitor agent should be considered. | 2b | B | 8.9±1.8 |
| 10. | When adjusting therapy, factors apart from disease activity, such as comorbidities and safety issues, should be taken into account. | 4 | D | 9.5±1.0 |
Recommendations with different levels of evidence within the recommendation are listed below.
The level of agreement was computed as a 0 to 10 scale, based on 28 voters within the group.
↵* In patients with active disease (particularly those with many swollen joints—usually ≥5, structural damage in the presence of inflammation, high ESR/CRP and/or clinically relevant extra-articular manifestations), treatment with disease-modifying drugs, such as methotrexate, sulfasalazine, leflunomide, should be considered;
↵† at an early stage.
↵‡ Local injections of corticosteroids should be considered as adjunctive therapy in psoriatic arthritis;
↵§ systemic steroids at the lowest effective dose may be used with caution.
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; EULAR, European League Against Rheumatism; PsA, psoriatic arthritis.