Dermatologist-rheumatologist consensus needed on steroids in PsA

Dermatologists and rheumatologists need to agree on the place of systemic glucocorticoids in the psoriatic arthritis (PsA) treatment landscape, clinicians say, given the persistent uncertainties surrounding their risk:benefit profile amid a lack of consensus and international guidelines.

According to an editorial published in Rheumatology, a “combined rheumatology dermatology consensus statement and decision making tool” is needed “to offer practical guidance on the risks and benefits for patients and clinicians around the world for the use of local and systemic glucocorticoids in PsA”.

The call, follows a systematic review led by dermatologists and rheumatologists in the Netherlands, also published in the journal, which they said “highlights the paucity, and low quality, of evidence for psoriasis flares with use of glucocorticoids” and indicates that “the perceived risks of psoriasis flare maybe greater than the received wisdom”.

The team identified very low rates of psoriasis flare across eleven retrospective cohorts spanning 6,727 people with PsA and 1,460,793 people with psoriasis who had been treated with any type of systemic glucocorticoid, and concluded that evidence recommending against their use was based on insufficient data.

With regard to efficacy, the review also showed that clinical evidence thus far supports the perception that both systemic and local glucocorticoids “appear to be effective of peripheral, axial and, occasionally, skin disease in people with PsA”, Dr William Tillett, of the Royal National Hospital for Rheumatic Disease in Bath, UK, and colleagues noted.

For example, data from an Italian study, involving 1,306 patients with PsA treated at 37 different centres, showed that 42% had received systemic glucocorticoids during their care, and that they were well-tolerated (92%) with high rates of efficacy (95%).

Also, authors of the Tight Control of PsA (TICOPA) study, which followed 206 patients with early PsA for a year, concluded that both intramuscular and intra-articular injections were effective, with no cases of psoriasis rated adverse events but and 8% risk of flare.

No consensus statements

While existing guidelines generally urge caution when administering systemic glucocorticoids, “at the present time there are no consensus statements or strong recommendations on the use of systemic glucocorticoids amongst people with PsA”, wrote Dr Tillett and colleagues.

EULAR’s PsA treatment guidelines state that local injections of glucocorticoids should be considered adjunctive therapy while systemic glucocorticoids may be used with caution at the lowest effective dose, but data on the risk of flares was not considered.

But new PsA guidelines from the British Society for Rheumatology (BSR), as well as those from The American College of Rheumatology (ACR) and the British Association of Dermatologists (BAD), only refer to immunomodulatory therapies and do not specifically refer to glucocorticoids, further highlighting the need for a consensus position.

In the meantime, findings from the review “should be considered in the context of the known benefits of glucocorticoids, and the well-established risks (beyond the skin) in the context of prevalent diabetes, hypertension and obesity in the PsA population to support shared decision making,” the authors stressed.

The also emphasised that “rheumatologists need to consider skin disease when commencing or switching any therapy (including GC) and liaise closely with dermatology when needed”.

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