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Professor Peter Nash
EULAR’s recommendations for the pharmacological treatment of psoriatic arthritis have been updated, emphasising safety and a cautious approach to JAK inhibitor treatment.
Most of the recommendations in the prior EULAR guidance from 2019 have been “modified substantially” due to new modes of action and new data on existing drugs. The guideline now also contains a new algorithm for the treatment of PsA and completely new advice on taking non-musculoskeletal manifestations of the disease into account when deciding on appropriate therapy.
New for 2024, the guideline task force of 36 international experts (including Professor Peter Nash from Australia) merged prior recommendations on the use of NSAIDs and glucocorticoids, given that “both only serve to relieve symptoms in the short term”.
Oral glucocorticoids were not recommended for patients with PsA. However, local injections could be considered adjunctive therapy to disease-modifying antirheumatic drugs (DMARDs) to temporarily relieve symptoms and inflammation.
The vast majority of patients should not be treated with NSAIDs alone; only those with very mild peripheral disease or with predominant entheseal or axial disease can potentially benefit from NSAID monotherapy; the task force noted and stressed that even in these cases, treatment should be limited to around four weeks.
“On the other hand, for patients with predominant axial disease who experience significant improvement in clinical symptoms, continuous NSAID use may be proposed if needed to control symptoms, always taking the risks and benefits into account,” they added in a paper published in Annals of the Rheumatic Diseases (link here).
Elsewhere, the update recommends that in patients with peripheral arthritis, clinicians should rapidly initiate treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) – with methotrexate the preferred choice – in those with clinically relevant skin presentation.
In patients who fail to respond adequately, treatment with a biological disease-modifying antirheumatic drug (bDMARD) should be started, but there was no preference for bDMARD mode of action.
JAK inhibitor caution
The task force cited various reasons for backing bDMARDs over JAK inhibitors (JAKi) at this stage of the treatment pathway.
“JAKi is efficacious in PsA, but the task force decided that at present, the efficacy-safety balance, costs and long-term experience with many bDMARDs favour their recommendation over JAKi. Relevant comorbidities in many patients with PsA also favour bDMARD selection,” the experts noted.