Table 3

Comparison of the 2019 and 2023 EULAR recommendations for the management of psoriatic arthritis

bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; DMARD, disease-modifying antirheumatic drug; IBD, inflammatory bowel disease; IL, interleukin; JAK, Janus kinase; JAKi, Janus kinase inhibitor; NSAID, non-steroidal anti-inflammatory drug; PDE4, phosphodiesterase 4; TNF, tumour necrosis factor; TNFi, tumour necrosis factor inhibitor; tsDMARD, targeted synthetic disease-modifying antirheumatic drug.

2019 version		Changes performed	2023 version
Overarching principles
A	Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment.	Unchanged	A	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.	Reformulated	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, patient preferences 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.	Reformulated	C	Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with psoriatic arthritis; in the presence of clinically relevant 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	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.
E	In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly.	Unchanged	E	In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly.
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.	Reformulated	F	When managing patients with psoriatic arthritis, non-musculoskeletal manifestations (particularly skin, eye and gastrointestinal tract) should be taken into account; comorbidities such as obesity, metabolic syndrome, cardiovascular disease or depression should also be considered.
		New	G	The choice of treatment should take account of safety considerations regarding individual modes of action to optimise the benefit–risk profile.
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.	Unchanged	1	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 and 3	Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms. 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.	Merged and modified	2	Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms; local injections of glucocorticoids may be considered as adjunctive therapy.
4 and 5	In patients with polyarthritis, a csDMARD should be initiated rapidly, with methotrexate preferred in those with relevant skin involvement. 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.	Merged and modified	3	In patients with polyarthritis, or those with monoarthritis/oligoarthritis and poor prognostic factors (eg, structural damage, elevated acute phase reactants, dactylitis or nail involvement), a csDMARD should be initiated rapidly, with methotrexate preferred in those with clinically relevant skin involvement.
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.	Split into two recommendations	4	In patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD should be commenced.
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.	Modified	5	In patients with peripheral arthritis and an inadequate response to at least one bDMARD, or when a bDMARD is not appropriate, a JAKi may be considered, taking safety considerations into account.
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.	Unchanged	6	In patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAKi is appropriate, 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.	Unchanged	7	In patients with unequivocal enthesitis and an insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered.
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	8	In patients with clinically relevant axial disease with an insufficient response to NSAIDs, therapy with an IL-17Ai, a TNFi, an IL-17 A/Fi or a JAKi should be considered.
		New	9	The choice of the mode of action should reflect non-musculoskeletal manifestations related to psoriatic arthritis; with clinically relevant skin involvement, preference should be given to an IL-17A or IL-17A/F or IL-23 or IL-12/23 inhibitor; with uveitis to an anti-TNF monoclonal antibody; and with IBD to an anti-TNF monoclonal antibody or an IL-23i or IL-12/23i or a JAKi.
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	10	In patients with an inadequate response or intolerance to a bDMARD or a JAKi, switching to another bDMARD or JAKi should be considered, including one switch within a class.
12	In patients in sustained remission, cautious tapering of DMARDs may be considered.	Reformulated	11	In patients in sustained remission, tapering of DMARDs may be considered.