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CONFERENCE UPDATE: EULAR 2023

The management of PsA: The 2023 update on EULAR recommendations

28 Jul 2023

Ever since the last European Alliance of Associations for Rheumatology (EULAR) recommendation update in 2019, multiple drugs for treating psoriatic arthritis (PsA) have been approved for use.¹ As such, an update on the EULAR recommendation in PsA management is much needed.¹ In the EULAR 2023 European Congress of Rheumatology, Dr. Laure Gossec, on behalf of the EULAR PsA task force which is composed of 36 members from 19 countries, introduced the revised and updated EULAR recommendations on managing PsA.¹ This update empathized on pharmacological non-topical treatment, musculoskeletal manifestations, and a balance between efficacy and safety.¹

The 2023 update has made major adjustments to the guideline, such as the introduction of an extra overarching principle, combining 2 pre-existing recommendations, and modifications to certain guidelines, resulting in a total of 7 principles and 11 recommendations (table 1 and 2).¹ Notable highlights of the modified recommendations include 1) limiting the use of short-term non-steroidal anti-inflammatory drugs (NSAIDs) monotherapies only for treating oligoarthritis with no poor prognostic factors, entheseal disease, and predominant axial disease; 2) incorporating methotrexate in combination with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) to treat skin conditions induced by polyarthritis and oligoarthritis with poor prognostic factors; 3) an entirely new recommendation that emphasizes the inspection of non-musculoskeletal manifestations.¹

Dr. Gossec acknowledged that in light of the introduction of newer drugs for treating PsA, patient safety remains the most dominant factor in treatment decision-making.¹ Utilizing a manifestation-oriented approach, the updated EULAR recommendation holds the potential to offer more tailored treatments for patients in the future.¹

Principles

PsA is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment.

Treatment of PsA patients should aim at the best care and must be based on a shared decision between the patient and the rheumatologist, considering the efficacy, safety, patient preferences, and costs.

Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with PsA; in the presence of clinically significant skin involvement, a rheumatologist and a dermatologist should collaborate in diagnosis and management.

The primary goal of treating patients with PsA is to maximize health-related quality of life, through control of symptoms, prevention of structural damage, normalization of function and social participation; abrogation of inflammation is an important component to achieve these goals.

In managing patients with PsA, consideration should be given to each musculoskeletal manifestation and treatment decisions made accordingly.

When managing patients with PsA, 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.

The choice of treatment should take account of safety considerations regarding individual modes of action to optimize the benefit-risk profile.

Table 1: Updated overarching principles of EULAR recommendations for managing PsA

EULAR: European Alliance of Associations for Rheumatology; PsA: Psoriatic arthritis

Recommendations	Level of Evidence	Grade
Treatment should aim at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy.	1b	A
NSAIDs may be used to relieve musculoskeletal signs and symptoms; local injections of glucocorticoids may be considered as adjunctive therapy.	1b/3b	A/C
In patients with polyarthritis, or those with mono-/oligoarthritis and poor prognostic factors (e.g., 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.	1b/4	B/C
In patients with peripheral arthritis and an inadequate response to at least 1 csDMARD, therapy with a bDMARD^{^} should be commenced.	1a	A
In patients with peripheral arthritis and an inadequate response to at least 1 bDMARD, or when a bDMARD is not appropriate, a JAKi may be considered, taking safety considerations^* into account.	1b/4	B/D
In patients with mild disease and an inadequate response to at least 1 csDMARD, in whom neither a bDMARD nor a JAKi is appropriate, a PDE4 inhibitor may be considered.	1b	B
In patients with unequivocal enthesitis and an insufficient response to NSAIDs, or local glucocorticoid injections, therapy with a bDMARD should be considered.	1b	B
In patients with clinically relevant axial disease with an insufficient response to NSAIDs, therapy with an IL-17A inhibitor, a TNFi, an IL-17A/F inhibitor or a JAKi^* should be considered.	1b	B
The choice of the mode of action should reflect non-musculoskeletal manifestations related to PsA: 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. With IBD to an anti-TNF monoclonal antibody or an IL-12/23i or IL-23i or a JAKi^*.	1b	B
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.	1b/4	C
In patients in sustained remission, tapering of DMARDs may be considered.	2b	B

Table 2: Updated EULAR recommendations for managing PsA

^{^}bDMARDs, this term includes here TNFi, drug targeting the IL-17, IL-12/23 and IL-23p19 pathways. No order of preference is given

^*For JAKis, caution is needed for patients aged 65 years or above, current, or past long-time smokers, with a history of atherosclerotic CV disease or their CV risk factors or with other malignancy risk factors; with known risk factors for VTE

bDMARDs: biological disease-modifying anti-rheumatic drugs; CV: Cardiovascular; csDMARDs: conventional synthetic disease-modifying anti-rheumatic drugs; DMARDs: disease-modifying anti-rheumatic drugs; EULAR: European Alliance of Associations for Rheumatology; IBD: Inflammatory bowel disease; IL17: Interleukin 17; IL12/23: Interleukin 12/23; IL23p19: Interleukin 23 subunit p19; JAKi: Janus kinase inhibitor; NSAIDs: Non-steroidal anti-inflammatory drugs; PDE4: Phosphodiesterase-4; PsA: Psoriatic arthritis; TNF: Tumor necrosis factor; TNFi: TNF inhibitor; VTE: Venous thromboembolism

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The management of PsA: The 2023 update on EULAR recommendations

RHEUMATOLOGY

28 Jul 2023