Comparison of the 2015 and 2019 recommendations
| 2019 (current) version | Changes performed | 2015 version | |
| Overarching principles | |||
| A | Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment. | Unchanged | Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment. |
| 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, considering efficacy, safety and costs. | Unchanged | 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, considering efficacy, safety and costs. |
| 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. | Unchanged | 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. |
| D | The primary goal of treating patients with psoriatic arthritis is to maximise health-related quality of life, through control of symptoms, prevention of structural damage, normalisation of function and social participation; abrogation of inflammation is an important component to achieve these goals. | Unchanged | The primary goal of treating patients with psoriatic arthritis is to maximise health-related quality of life, through control of symptoms, prevention of structural damage, normalisation of function and social participation; abrogation of inflammation is an important component to achieve these goals. |
| E | In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly. | New | Not applicable. |
| F | When managing patients with psoriatic arthritis, non-musculoskeletal manifestations (skin, eye and gastrointestinal tract) should be taken into account; comorbidities such as metabolic syndrome, cardiovascular disease or depression should also be considered. | Rephrased | When managing patients with psoriatic arthritis, extra-articular manifestations, metabolic syndrome, cardiovascular disease and other comorbidities should be taken into account. |
| Recommendations | |||
| 1 | Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy. | Rephrased | Treatment should be aimed at reaching the target of remission or, alternatively, minimal/low disease activity, by regular monitoring and appropriate adjustment of therapy. |
| 2 | Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms. | Rephrased | In patients with psoriatic arthritis, non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms. |
| 3 | Local injections of glucocorticoids should be considered as adjunctive therapy in psoriatic arthritis; systemic glucocorticoids may be used with caution at the lowest effective dose. | Renumbered | Local injections of glucocorticoids should be considered as adjunctive therapy in psoriatic arthritis; systemic glucocorticoids may be used with caution at the lowest effective dose. |
| 4 | In patients with polyarthritis, a csDMARD should be initiated rapidly, with methotrexate preferred in those with relevant skin involvement. | Modified | In patients with peripheral arthritis, particularly in those with many swollen joints, structural damage in the presence of inflammation, high ESR/CRP and/or clinically relevant extra-articular manifestations, csDMARDs should be considered at an early stage, with methotrexate preferred in those with relevant skin involvement. |
| 5 | In patients with monoarthritis or oligoarthritis, particularly with poor prognostic factors such as structural damage, high erythrocyte sedimentation rate/C reactive protein, dactylitis or nail involvement, a csDMARD should be considered. | New | Not applicable but partly covered in the recommendation above. |
| 6 | In patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD should be commenced; when there is relevant skin involvement, an IL-17 inhibitor or IL-12/23 inhibitor may be preferred. | Modified and merged | In patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD, usually a TNF inhibitor, should be commenced. In patients with peripheral arthritis and an inadequate response to at least one csDMARD, in whom TNF inhibitors are not appropriate, bDMARDs targeting IL-12/23 or IL-17 pathways may be considered. |
| 7 | In patients with peripheral arthritis and an inadequate response to at least one csDMARD and at least one bDMARD, or when a bDMARD is not appropriate, a JAK inhibitor may be considered. | New | Not applicable. |
| 8 | In patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAK inhibitor is appropriate, a PDE4 inhibitor may be considered. | Modified | In patients with peripheral arthritis and an inadequate response to at least one csDMARD, in whom bDMARDs are not appropriate, a targeted synthetic DMARD such as a PDE4 inhibitor may be considered. |
| 9 | In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered. | Modified | In patients with active enthesitis and/or dactylitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor. |
| 10 | In patients with predominantly axial disease which is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor; when there is relevant skin involvement, IL-17 inhibitor may be preferred. | Modified | In patients with predominantly axial disease that is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNF inhibitor. |
| 11 | In patients who fail to respond adequately to, or are intolerant of a bDMARD, switching to another bDMARD or tsDMARD should be considered*, including one switch within a class†. | Modified | In patients who fail to respond adequately to a bDMARD, switching to another bDMARD should be considered, including switching between TNF inhibitors. |
| 12 | In patients in sustained remission, cautious tapering of DMARDs may be considered. | New | Not applicable. |
csDMARDs include methotrexate, sulfasalazine or leflunomide; bDMARDs include here TNF inhibitors (both original and biosimilars) and drugs targeting the IL-17 and IL-12/23 pathways.
bDMARDs, biological disease-modifying antirheumatic drugs; CRP, C reactive protein; csDMARDs, conventional synthetic disease-modifying antirheumatic drugs; DMARDs, disease-modifying antirheumatic drugs; ESR, erythrocyte sedimentation rate; IL, interleukin; JAK, Janus kinase; NSAIDs, non-steroidal anti-inflammatory drugs; PDE4, phosphodiesterase-4; TNF, tumour necrosis factor; tsDMARDs, targeted synthetic disease-modifying antirheumatic drugs.