New guidelines for psoriatic arthritis (PsA) recommend a treat-to-target approach with first-line use of TNFi biologics and smoking cessation.

Published by the American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF), the new guidelines also include recommendations for psoriatic spondylitis, predominant enthesitis, and treatment of patients who also have IBD, diabetes, or serious infections.

Some key recommendations from the guideline include:

• A conditional recommendation to use treat-to-target approach for all patients with active PsA;
• A conditional recommendation to use TNF inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA;
• 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 principal author Dr Jasvinder Singh, of the University of Alabama Division of Clinical Immunology and Rheumatology.

“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.”

However the guideline authors acknowledge that the levels of evidence used to inform the recommendations – particularly comparisons of newer therapies – are moderate to low. This led to nearly all recommendations being conditional.

“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,” said Dr Singh.

“We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches.”

While current GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) 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 such as methotrexate, leflunomide and sulfasalazine.

“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first,” said Dr Dafna Gladman, a rheumatology professor of medicine at the University of Toronto, 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.”

The JAK inhibitor tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs, especially with regard to risks .

The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics as well as the well-established link of smoking with mortality, cancers and heart and lung diseases.