Newly released psoriatic Arthritis (PsA) treatment guidelines from the National Psoriasis Foundation (NPF) and the American College of Rheumatology (ACR) are calling for a treat-to-target approach for all patients with active PsA.

What’s more, the guidelines conditionally recommend use of tumor necrosis factor inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA and offer a strong recommendation for smoking avoidance/cessation.

“Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” says Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama at Birmingham who served as principal investigator for the guideline project, in a news release. “The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation.”

While current GRAPPA recommendations address the use of TNFi biologics in treatment-naïve patients, this is the first guideline that specifically recommends first trying them over oral small molecule (OSM) drugs.

“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first,” adds Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and member of the NPF Medical Board who served as a content expert on the guideline’s core team. “This doesn’t hold true once other symptoms and comorbidities are present, so OSMs can continue to be a first-line option for patients that have contraindications to TNFi treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy. Providers should take into consideration all active disease domains, comorbidities, and the patient’s functional status when choosing the optimal therapy for an individual at a given point in time.”

(Tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs.)

The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics; the benefits of smoking cessation; and the well-established link of smoking with mortality, cancers and heart and lung diseases in the general population, the guideline authors state.

The guidelines also include recommendations for vaccinations, psoriatic spondylitis, predominant enthesitis, and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections. 

The PsA guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. Due to limited data in some areas, the quality of evidence was often graded low or very low. This led to nearly all recommendations being conditional. A voting panel of rheumatologists, dermatologists, health professionals, and patients achieved consensus on the direction and the strength of the recommendations.

“Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions,” says Singh. “This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations.”

The complete guideline is available online on both the ACR website and NPF website.