Table 1

2019 EULAR recommendations for the pharmacological management of psoriatic arthritis, with levels of evidence, grade of recommendations and level of agreement

Overarching principlesLevel of agreement, mean (SD)
APsoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment.9.9 (0.4)
BTreatment 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)
CRheumatologists 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)
DThe 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)
EIn managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly.9.9 (0.3)
FWhen 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)
RecommendationsLevel of evidenceGrade of recommendationLevel of agreement, mean (SD)
1Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy.1bA9.4 (1.0)
2Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms.1bA9.6 (0.8)
3Local 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*
C9.5 (1.1)
4In patients with polyarthritis, a csDMARD should be initiated* rapidly†, with methotrexate preferred in those with relevant skin involvement*.1b*
B9.5 (0.8)
5In 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.4C9.3 (1.0)
6In 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.1bB9.4 (1.1)
7In 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.1bB9.2 (1.3)
8In 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*
B8.5 (1.9)
9In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered.1bB9.3 (0.9)
10In 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.1bB9.7 (0.6)
11In 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*
C9.5 (1.2)
12In patients in sustained remission, cautious tapering of DMARDs may be considered.4C9.5 (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.