PsA Treatment Guidelines Lead with Treat-to-Target

The January issue of Arthritis and Rheumatology includes updated treatment guidelines for adults with active psoriatic arthritis (PsA). The guidelines, by the American College of Rheumatology and the National Psoriasis Foundation, address how best to prescribe oral small molecules, tumor necrosis factor inhibitors, IL-12/23i inhibitors, IL-17 inhibitors, CTLA4-Ig (abatacept) and the JAK inhibitor tofacitinib. In addition to stressing specific critical outcomes for treatment, the guidelines also address treatment recommendation for PsA cases complicated by psoriatic spondylitis, predominant enthesitis, inflammatory bowel disease, diabetes or serious infections.

Most of the recommendations were conditional in that the decision to pursue a treatment strategy should be made as a result of a discussion between physician and patient that covers pre-existing conditions, adverse events, the cost of therapy and other key factors, such as the quality of clinical evidence for the recommendation. Unless described as a “strong” recommendation, the recommendations listed here fall under “conditional.”

In adult patients with active PsA despite treatment with an oral small molecule:

• Switch to a TNF biologic over: a different oral small molecule, IL-17, IL-12/23, abatacept, tofacitinib.
• IL-17 is preferred over a  different oral small molecule, IL-12/23, abatacept, tofacitinib.
• IL-12/23 is preferred over a  different oral small molecule, IL-12/23, abatacept, tofacitinib
• Add apremilast to current oral small molecule therapy over switching to apremilast.
• Switch to another oral small molecule (except apremilast) over adding another oral small molecule (except apremilast) to current treatment.
• Switch to a TNF biologic monotherapy over methotrexate and a TNF biologic combination therapy.
• Switch to an IL-17 biologic monotherapy over methotrexate and an IL-17 biologic combination therapy.
• Switch to an IL-12/2 biologic monotherapy over MTX and an IL-12/23 biologic combination therapy.

For patients with active PsA who have never before been treated for the condition:

• Treat with a TNF biologic or an oral small molecule over IL-17 and IL-12/23 inhibitors.
• Methotrexate is preferred over NSAIDs.
• IL-17 inhibitors, if needed, are preferred ovver IL-12/23 biologics.

In adult patients with active PsA despite treatment with a TNF biologic monotherapy:

• Switch to a different TNF  biologic over switching to an IL-17i biologic, an IL-12/23i biologic, switching to abatacept or tofacitinib or over adding methotrexate.
• Switch to an IL-17 biologic over switching to an IL-12/23i biologic, abatacept or tofacitinib.
• Switch to an IL-12/23 biologic over abatacept or tofacitinib.
• Switch to a different TNF biologic monotherapy over switching to a different TNF biologic and methotrexate combination therapy.
• Switch to an IL-17 biologic monotherapy over switching to an IL-17i biologic and methotrexate combination therapy.
• Switch to an IL-12/23  biologic monotherapy over switching to an IL-12/23  biologic and methotrexate combination therapy.

For patients on combo therapy with a TNF biologic and methotrexate:

• Switch to a different TNF biologic with methotrexate over switching to a different TNF  biologic monotherapy.
• Switch to an IL-17 biologic monotherapy over an IL-17 biologic and methotrexate  combination therapy.
• Switch to IL-12/23 biologic monotherapy over IL-12/23 biologic and methotrexate combination therapy.

Recommendations for patients who have been treated with IL-17 biologic monotherapy:

• Switch to a TNF biologic over switching to an IL-12/23 biologic, over a TNFi biologic over a different IL-17, over adding methotrexate to an IL-17 biologic.
• Switch to an IL-12/23 biologic over a different IL-17 biologic  or over methotrexate to an IL-17 biologic.

In adult patients with active PsA who were treated with IL-12/23i biologic monotherapy:

• Switch to a TNF biologic over an IL-17 or over adding methotrexate to an IL-12/23.
• Switch to an IL-17 biologic over adding methotrexate over an IL-12/23i biologic.

Recommendations for PsA patients with axial disease or enthesitis:

• Adopt a treat-to-target strategy.
• For patients with psoriatic spondylitis/axial disease despite having been treated with NSAIDs, switch to a TNF biologic instead of an IL-17 biologic; switch to a TNF biologic over an IL-12/23 inhibitor; switch to an IL-17 biologic over an IL-12/23 inhibitor.
• For patients with predominant enthesitis who have never before taken oral small molecules or biologics, oral NSAIDs, TNFi biologics and tofacitinib are preferred over apremilast.
• Patients with predominant enthesitis despite having had treatment with oral small molecules (OSM), switch to a TNF biologic over an IL-17, IL-12/23 or another oral small molecule. IL-17 biologics are preferred over IL-12/23 or another OSM and IL-12/23 is preferred over another oral small molecule.

Recommendations for PsA patients with inflammatory bowel disease:

• Treatment naïve patients should be started on a monoclonal antibody TNF biologic over an oral small molecule.
• For PsA patients with IBD who have tried oral small molecules, it is strongly recommended that patients be switched to a monoclonal antibody TNF over a TNF biologic soluble receptor biologic, such as etanercept, or over an IL-17.
• There was a conditional recommendation to prefer a TNF over an IL-12/23 inhibitor, but then a strong recommendation to switch to an IL-12/23 biologic over an IL-17 inhibitor.

Recommendations for patients with diabetes and recurrent serious infections:

• For treatment naïve patients, first start with an oral small molecule instead of methotrexate or a TNF biologic.
• For treatment naïve patients with frequent serious infections it is strongly recommended that patients start on an oral small molecule over a TNF biologic; or, start on an IL-12/23 biologic over a TNF biologic; or, an IL-17 biologic over a TNFi biologic.

Recommendations for vaccination:

• Administering vaccines with biologics largely depends on the patient’s specific case. In most cases, biologics and vaccines can be administered together.

Recommendations for nonpharmacologic interventions:

• Pursue low-impact exercise, physical therapy, occupational therapy, weight loss for overweight patients, massage therapy, acupuncture, smoking cessation (strong recommendation).

References:

Singh JA, Guyatt G, Ogdie A, et al. "Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis," Arthritis Rheumatol. 2019 Jan;71(1):5-32. DOI: 10.1002/art.40726. Epub 2018 Nov 30.