2019 EULAR recommendations for the pharmacological management of psoriatic arthritis, 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. | 9.9 (0.4) |
| 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. | 9.8 (0.5) |
| 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. | 9.8 (0.7) |
| 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. | 9.9 (0.4) |
| E | In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly. | 9.9 (0.3) |
| 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. | 9.8 (0.6) |
| Recommendations | Level of evidence | Grade of recommendation | Level of agreement, mean (SD) | |
| 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. | 1b | A | 9.4 (1.0) |
| 2 | Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms. | 1b | A | 9.6 (0.8) |
| 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†. | 3b* 4† | C | 9.5 (1.1) |
| 4 | In patients with polyarthritis, a csDMARD should be initiated* rapidly†, with methotrexate preferred in those with relevant skin involvement*. | 1b* 5† | B | 9.5 (0.8) |
| 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. | 4 | C | 9.3 (1.0) |
| 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. | 1b | B | 9.4 (1.1) |
| 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. | 1b | B | 9.2 (1.3) |
| 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. | 5* 1b† | B | 8.5 (1.9) |
| 9 | In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered. | 1b | B | 9.3 (0.9) |
| 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. | 1b | B | 9.7 (0.6) |
| 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†. | 1b* 4† | C | 9.5 (1.2) |
| 12 | In patients in sustained remission, cautious tapering of DMARDs may be considered. | 4 | C | 9.5 (0.9) |
The level of agreement was computed on a 0–10 scale.
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; csDMARDs, conventional synthetic disease-modifying antirheumatic drugs; DMARDs, disease-modifying antirheumatic drugs; EULAR, European League Against Rheumatism; IL, interleukin; JAK, Janus kinase; NSAIDs, non-steroidal anti-inflammatory drugs; PDE4, phosphodiesterase-4; TNF, tumour necrosis factor.