GRAPPA Refines Recommendations on Psoriatic Disease Treatment

Sara Freeman

June 08, 2021

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has included more drugs and data and is moving toward a slightly more stepped approach to treating some forms of psoriatic disease in the latest iteration of their recommendations.

Dr Laura Coates

"There's been an explosion over the last few years in terms of the number of medications," available to treat psoriasis and psoriatic arthritis, Laura C. Coates, MBChB, PhD, said in an interview ahead of presenting the draft recommendations at the annual European Congress of Rheumatology.

"The good thing about having more drugs is you've got more choice, but actually it makes these recommendations even more important because it becomes more complicated to choose optimal treatment for individuals," added Coates, a senior clinical research fellow at the University of Oxford (England).

Dr Laure Gossec

"We've been waiting for a while now for the new GRAPPA recommendations," Laure Gossec, MD, PhD, of Sorbonne University and Pitié-Salpêtrière Hospital in Paris, said in a separate interview.

The last version of the guidelines was developed in 2015 and published in 2016, and since then there have been new data on Janus kinase inhibitors and interleukin-23 inhibitors, for example, which have now been incorporated into the updated recommendations alongside the old stalwarts of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and tumor necrosis factor inhibitors.

"I think that we can see some similarities but also differences compared to the previous version of the recommendations," Gossec said.

One similarity is that the recommendations retain their modular or domain-oriented approach, keeping the core way that clinicians can use the recommendations based on their patients' presentations. So, they still cover the management of peripheral arthritis, axial disease, enthesitis, dactylitis, and skin and nail disease individually.

What's different, however, is that the domain on comorbidities has been split into two to cover general comorbidities and to give more specific guidance on managing inflammatory bowel disease (IBD) and uveitis, "both of which may not 'strictly speaking' be treated by rheumatologists or dermatologists, but are manifestations which can appear in psoriatic disease," Gossec noted.

IBD and uveitis "are part of the whole spondyloarthritis syndrome and are genetically related," Coates said in her interview. "A lot of the drugs have licenses in those particular areas. The evidence is much stronger for which medication you should choose if somebody has psoriatic arthritis and Crohn's disease or psoriatic arthritis and uveitis," she noted.

When it comes to the rest of the comorbidities, think "cardiovascular disease, liver disease, infections – all the 'normal' comorbidities," she added, noting "that's usually where there's a lot less data" on which drug to use.

New Overarching Principle and Position Statements

The goal of the recommendations hasn't really changed since the first iteration of the guidelines in 2009, Coates noted in her presentation. They are intended to provide clinicians with recommendations "based on the best available evidence" for the management of patients with psoriatic disease.

To that end, a through process was followed, starting with the setting of PICO (Patient/population/problem; intervention; comparison; outcome) questions followed by systematic literature searches, data extraction, and review that assess the quality of evidence and then grade it accordingly before using it to inform the recommendation statements.

There is a new overarching principle that says: "These recommendations, which include the most current data concerning the optimal assessment of and therapeutic approached to psoriatic arthritis, present contextual considerations to empower shared decision making."

The other overarching principles remain the same as in the 2015 version, with "minor wording changes particularly around the comorbidities overarching principle," Coates said.

Also new are two position statements. "One of them is specifically around biosimilars, because that's been a big shift since 2015," Coates said. "It has basic rules about what evidence there should be, what we should consider when we're using them, and patient involvement and decision making."

The second statement covers "similar advice on tapering or discontinuing therapy – what we do when people are doing really well, how we should stop or taper, and which drugs we should choose to stop along with shared decision making with patients."

GRAPPA Intentionally Gives Clinicians More Freedom

While there may be data to show differences in efficacy and side effects between the various drugs cited in the recommendations, "GRAPPA makes the choice to not prioritize one drug over another," Gossec said. This decision gives "a lot of freedom then to the physician to make the decision."

One important change according to Gossec is that oral "NSAIDs have clearly been put back as first-line treatment, before going on to disease-modifying drugs for most of the musculoskeletal manifestations. She added that for skin manifestations, topical NSAIDs were recommended, but that NSAIDs were more recommended for IBD and uveitis of course.

"I feel that's a big step towards more of a step-up approach," Gossec said. "The old recommendations were not clear that you would precede an NSAID before moving on to a disease-modifying drug. So, I think that makes it a little bit more similar to the 2019 EULAR recommendations." The use of csDMARDs such as methotrexate has also been "pushed up a notch" in peripheral arthritis, she said.

What's Next?

There are a few fine tunings still to be made before the final recommendations are published. They also have to be discussed at the meeting of the GRAPPA task force, which consists of rheumatologists, dermatologists, and patient representatives.

Besides the recommendations manuscript, there will be individual papers detailing the evidence underpinning the recommendations in each of the eight domains, Coates noted. Those "will look at relative efficacy in detail," she said. "There will be a lot more discussion/evidence summary included" to help with drug selection.

"We also plan to have some case studies to illustrate how the recommendations can be used, similar to that included in the 2015 recommendations," she added.

Paul Studenic, MD, PhD, of the Karolinska Institute in Stockholm and Medical University of Vienna, tweeted that the GRAPPA recommendations showed treatment "needs to be tailored to the patient" taking "comorbidities as well as the heterogeneity of features of the clinical presentation into account."

He said in an interview: "The third edition of the GRAPPA is a huge collaborative effort." The new overarching principle put the recommendations in the context of shared decision making and, he added, they emphasize an "integrated management plan taking not only 'classical'-related manifestations like uveitis into account but [also] a spectrum of comorbidities and reproductive health."

GRAPPA is a not-for-profit organization and receives funding from multiple pharmaceutical companies. Currently this includes AbbVie, Amgen, Bristol-Myers Squibb, Boehringer Ingelheim, Janssen, Eli Lilly, Novartis, Pfizer, UCB, and Sun Pharma with Galapagos and Nordic Bioscience as Innovation Partners. Coates acknowledged receiving research funding, honoraria, speaker fees or all of these from most of the aforementioned companies.

Gossec has received research funding or other support from numerous pharmaceutical companies and is a member of GRAPPA and the task force that developed the EULAR guidelines on the pharmacological management of psoriatic arthritis.

Studenic had nothing to disclose.

This article originally appeared on, part of the Medscape Professional Network.


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