New Psoriatic Arthritis Recommendations Tailored to Rheumatologists

Alice Goodman

June 21, 2010

June 21, 2010 (Rome, Italy) — A European League Against Rheumatism (EULAR) Task Force unveiled proposed recommendations for the management of psoriatic arthritis (PsA) here at EULAR 2010.

The new guidelines, presented by Laure Gossec, MD, from the Department of Rheumatology at René Cochin Hospital in Paris, France, were developed specifically for rheumatologists. The only existing recommendations were developed by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), and dermatologists were "very involved in this process," noted Dr. Gossec.

"EULAR wanted to be proactive about developing recommendations by rheumatologists for rheumatologists," she told listeners. "We wanted easy-to-apply recommendations from the rheumatologist's point of view."

Developed by the EULAR Task Force over a 6-month period, the 10 agreed-upon recommendations are based on varying levels of evidence, including randomized controlled trials, meta-analyses, other types of studies, and expert opinion on the management of PsA. The recommendations are restricted to pharmacologic management and do not include topical treatments.

"The recommendations are based on 5 overarching principles," Dr. Gossec explained.

The first principle is that PsA is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment, with emphasis on the word "may," because milder forms will not need this approach, she said.

The second principle is that the treatment of PsA should be based on best care, with shared decision-making by rheumatologists and patients. Rheumatologists should manage musculoskeletal manifestations, and can collaborate with dermatologists for skin involvement. The primary goal of treatment is to maximize quality of life, with remission as an important target to achieve this goal. Rheumatologists should monitor patients and adjust treatment appropriately.

The gist of the new recommendations is as follows:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as first-line treatment for musculoskeletal signs and symptoms in PsA patients with joint involvement.

  • Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, sulfasalazine, and leflunomide, should be considered early-stage treatment in patients with active disease and manifestations of structural damage plus inflammation.

  • For active PsA and clinically relevant psoriasis, a DMARD that also improves psoriasis, such as methotrexate, should be considered.

  • Patients with active PsA and an inadequate response to at least 1 systemic DMARD, such as methotrexate, should be treated with a tumor necrosis factor (TNF) inhibitor.

  • TNF inhibitors should be considered first-line treatment for patients with active enthesitis and/or dactylitis, those with predominant axial disease who have had an insufficient response to NSAIDs or local steroids, and patients with very active PsA who DMARD treatment-naive, particularly those with swollen joints, structural damage in the presence of inflammation, and/or clinically relevant extraarticular manifestations, especially extensive skin involvement.

  • Failure to respond to 1 TNF inhibitor warrants consideration of a switch to another TNF inhibitor.

  • When adjusting therapy, apart from disease activity, comorbidities and safety issues should be addressed.

"This is the gist of the new EULAR recommendations. They will continue to be refined over the next years. The task force is also in the process of developing a research agenda based on these recommendations," Dr. Gossec said.

"This set of recommendations recently issued by EULAR is largely noncontroversial. [The recommendations] were based on a systematic evidence review and 'interpreted' by specialists in the field," said Philip Helliwell, MD, from Leeds Institute of Molecular Medicine, Section of Musculoskeletal Disease, University of Leeds, United Kingdom. Dr. Helliwell cochaired the session in which the recommendations were presented.

Dr. Helliwell took issue with one of the proposed recommendations — that patients with active dactylitis not be given DMARDs, opting instead for a TNF inhibitor.

"That recommendation was based largely on lack of evidence. Most rheumatologists would use a local steroid injection and try a DMARD before proceeding," he explained.

Dr. Gossec and Dr. Helliwell have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2010: Clinical Science Session. Early Psoriatic Arthritis. Presented June 18, 2010.


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