Psoriatic arthritis

New PsA guidelines don’t “beat around the bush”

Psoriatic arthritis treatment guidelines unveiled at the American College of Rheumatology congress last week have elevated TNF inhibitors to a first-line therapy.

Speaking during a press briefing Dafna Gladman MD, a Professor of Medicine at the University of Toronto, accused other guidelines of “skirting around the fact” there’s no evidence that methotrexate works for PsA.

“It’s refreshing and reassuring that when you do an appropriate, evidence-based approach, you finally find the truth in front of you, and you have TNF inhibitors as the first-line treatment,” she said.

“Obviously, they’re not for everybody. There are patients in whom we cannot use TNF inhibitors, either because they don’t like needles, or because they have contraindications…, but at least we have a recommendation for the use of these drugs as a first-line treatment,” she told members of the media.

“This is an exciting time and I really hope that other groups who are developing guidelines will come around and follow this example… Evidence based medicine needs to be practiced.”

Alexis Ogdie, a rheumatologist who practices at the University of Pennsylvania, Philadelphia, and was also involved in the development of the guidelines said she was excited she could use TNF inhibitors first-line in her patients.

“When we have patients come in with very severe disease, occasionally they also have severe psoriasis, so we’ve been able to use TNF inhibitors as first-line treatment in some of our patients in Pennsylvania. This differs state by state.

But the exciting thing is that they get better so fast and you don’t have to tell them to wait 8-12 weeks for methotrexate to work…I am excited that we now have this option for patients,” she said.

Transparency in evaluating evidence

According to the guideline’s principal investigator, Dr Jasvinder Singh Professor of Medicine and Epidemiology at the University of Alabama at Birmingham, a key strength of the guidelines was the fact that it used the Grading of Recommendations Assessment, Development and Evaluation (GRADE)  methodology.

This system uses systematic reviews of the scientific literature available to evaluate and grade the quality of evidence in a particular domain.

“Some processes will take RCTS to be gold… but there are randomised trials, and there are randomised trialsthere are poorly done randomised trials and there are very well done observational studies” Dr Singh explained.

“The GRADE process allows you not only to see how effective something is but couples that with the quality of evidence.

If evidence comes from poorly RCTS then the evidence is low.  It’s like anything else, quality does matter it is not just about quantity,” he said.

A sneak (treatment) peek

Unveiling a few of the highlights from the guideline during a conference session Dr Singh said a treat-to-target strategy approach was recommended. When patients continue to have active PsA despite being on a TNF inhibitor, the draft guideline recommends switching to a different TNF inhibitor instead of switching to an IL-17 inhibitor, an IL-12/IL-23 inhibitor, or adding methotrexate.

If PsA is still active, the guideline recommends switching to an IL-17 inhibitor instead of an IL-12/IL-23 inhibitor, abatacept, or tofacitinib.

If PsA is still active, the guideline recommends switching to an IL-12/IL-23 inhibitor over abatacept or tofacitinib.

The guideline also introduces new nomenclature. DMARDs have been renamed oral small molecules, or OSMs, to more clearly distinguish them from biologic agents.

Vaccination strategy

Clinicians are also advised to start a biologic and administer a killed vaccines (as indicated) in patients with active PsA rather than delay treatment. But delaying treatment is advised when administering a live attenuated vaccine.

Non-pharmacologic treatment

The draft guidelines also recommend low impact exercise, weight loss and smoking cessation. Conditional recommendations include exercise (with low-impact exercise, such as Tai Chi, yoga, or swimming, noted as being preferable to high-impact exercise); physical therapy; occupational therapy; weight loss in the case of patients who are overweight or obese; massage therapy; and acupuncture.

The guidelines, created in partnership with the NPF,  is under peer review and is expected to be published in the (European) summer of 2018.

Relevance to Australia

Speaking to the limbic, Dr Peter Nash a rheumatologist in Maroochydore, Queensland, said the recommendations advocated for a treat-to-target strategy despite there being little consensus on what the treatment target would look like and failed to recommend a disease activity measure.

“Is it DAPSA remission,  minimal disease activity (MDA), or very low disease activity (VLDA)?” he asked.

However, Dr Nash acknowledged that the committee were “brave enough” to state the lack of evidence for methotrexate, a point that he said was a long bone of contention for “recommendations”.

“But the PBAC has never worried about  strict evidence, eg. there is no evidence for methotrexate, or sulphasalazine or leflunomide in PsA enthesitis, dactylitis, axial disease, arthritis mutilans, nails, or ability to prevent radiological progression and still our patients have to fail two of these agents to eligible for bDMARDs,” he said.

According to Dr Nash the recommendations are interesting for Australian rheumatologists, represent a huge amount of work, and reveal just how large the evidence gaps are in PsA management.

“Unfortunately [the recommendations] will change little as we are bound by non-evidence based reimbursement rules,” he added.

Dr Peter Nash chaired the Axial section of the GRAPPA recommendations.

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