Psoriatic arthritis

What the GRAPPA?

Clinical outcomes for patients with psoriatic arthritis could be improved thanks to GRAPPA. Not the throat-warming Italian drink, but rather the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), which recently updated its recommendations for treating patients with PsA. But what’s new about them, and how do they differ from EULAR recommendations? In this in-depth feature we speak to Dr Laura Coates Member of the international GRAPPA group and Dr Peter Nash gives his thoughts on their relevance to Australian clinicians and patients.


What’s changed?

In this latest iteration of recommendations, the international group comprising rheumatologists, dermatologists and patients with PsA has added six new overarching principles for the care of adults with PsA.

It has also developed treatment recommendations and a schema incorporating the principles for all the key domains of PsA – arthritis, spondylitis, enthesitis, dactylitis and skin, and nail disease, including associated comorbidities such as cardiovascular disease, obesity and diabetes. (Arthritis & Rheumatology 2016; 68(5): 1060–71.)

The most strongly endorsed principle is that the goals of treatment are to achieve the lowest possible level of disease activity in all domains of disease; to optimise functional status, improve quality of life and wellbeing and prevent structural damage to the greatest extent possible; and avoid or minimise complications, both from untreated active disease and from therapy.

The new recommendations update those published by GRAPPA in 2009, and according to lead author Dr Laura Coates NIHR Clinical Lecturer in Rheumatology at the University of Leeds, UK, are much needed because the research has advanced quickly since then.

Several new compounds have been approved since the previous literature review, so the recommendations now include more therapy options in each of the key domains of PsA, she said.

There have also been significant improvements in the diagnosis and monitoring of the disease, particularly in recognising the important contribution of comorbidities related to PsA.

So this time round, GRAPPA added a new group focused on comorbidities to assess their role in general management (eg screening and appropriate referral) as well as their effect on treatment.

Other improvements include separating out skin and nail disease to allow delineation of the data between the two, and giving patients with PsA more of a voice, which Dr Coates says is important to gain additional perspective.

“Judgement on different therapy recommendations is not just based on evidence published but also on physician and patient experience and opinion,” she said.

Improving patient outcomes

Dr Coates believes the new recommendations should improve patient outcomes because they provide much more evidence on how patients with PsA should be treated.

And not just in terms of the major therapeutic advances but also through a better understanding of the disease and its assessment, particularly that identifying comorbidities is critical in the optimal management and treatment of PsA patients.

Speaking to the limbic, she explained how the overarching principles could help healthcare teams develop their local management pathways.

“They can be applied to individual patients to help management decisions following the schema. Doctors should assess disease activity in the different domains of PsA in each individual, then use the schema to identify appropriate treatments, ideally to address as many domains as possible with one drug.

“The comorbidities table can be used if a patient has key comorbidities to see if certain drugs may be either a) useful for treating that comorbidity directly (eg Crohn’s disease) or b) contraindicated or require special monitoring because of the comorbidity.”

Similar but different to EULAR 

Since GRAPPA is an international group the recommendations are designed to be applied across countries, although Dr Coates cautions this can be difficult because the majority of the evidence comes from North America or Western Europe, with some from Australasia.

Applying them internationally also requires maximal flexibility in the recommendations, as different healthcare systems will have different access to therapies, she noted.

According to Dr Coates the new recommendations are very similar to those developed by EULAR, also updated recently, despite the groups using slightly different methodologies.

But while EULAR focuses only on rheumatology and provides no advice on the treatment of skin, the recommendations from GRAPPA are aimed at dermatologists and rheumatologists.

There is also important information for other physicians treating PsA, including GPs who often coordinate complex care when patients are seeing multiple specialties, she added.

GRAPPA is already in the early stages of planning for a further update to its treatment recommendations in 2020.

The Australian perspective – by Dr Peter Nash

Why go to such considerable efforts to write recommendations such as the EULAR and GRAPPA recommendations for the management of PsA?

Believe it or not, there is a constant demand from individual clinicians all over world, particularly Asia, Middle East and South America, for the latest evidence based recommendations to assist in daily clinical practice.

Countries also want help in developing their own National Association recommendations without reinventing the wheel.

What’s more, they want to use these “best practice” recommendations to obtain better and funded access to therapy for patients.

The recommendations are used by different specialities for teaching purposes and dermatology associations have looked to them for recommendations for their members.

It is relevant to note that they are “recommendations” not “guidelines” are described throughout in an attempt to lessen medico-legal implications.

The differences between the EULAR and GRAPPA recommendations

 Both sets of recommendations have their value and their limitations; both have an extensive research agenda to fill in gaps in evidence.

 The EULAR recommendations include:

  • The opinion of 27 rheumatologists;
  • Limited dermatology input (one dermatologist);
  • A non-domain approach;
  • No advice on skin or nails;
  • NSAIDs remain first line therapy for an extended period 3-6 months;
  • MTX use is based on observational data such as TICOPA and Norwegian registry data, with a recommendation to continue MTX with bDMARDs;
  • TNF inhibitors are recommended after a single failed csDMARD;
  • Comorbidities and cost considerations have been added;
  • Treatment target remission is not validated and poorly defined, but Minimal Disease Activity is mentioned as an alternative;
  • The use of DAPSA (disease activity score borrowed from reactive arthritis) is promoted – while it is an excellent peripheral arthritis activity score it leaves out enthesitis dactylics axial skin and nails.

GRAPPA recommendations

The GRAPPA update of the management of PsA recommendations includes approval and consensus from over 500 rheumatologists and dermatologists as well as patient representatives.

They include:

  • An extensive literature review for all appropriate evidence published since the previous recommendations including abstracts and presentations at major meetings;
  • A domain based approach across the two specialties that included all joint domains as well as skin and nails;
  • An emphasis on comorbidities and their management; and
  • GRADE and PICO methodology.

Important developments include the addition of IL12/23, PDE4 and IL17 inhibitors to domains where supporting evidence has been presented.

Where ‘abstract only’ data exists “greyed out” text has been applied, which will be changed to normal text as peer reviewed publications are published.

This was much debated, but the consensus was for inclusion in this format so that the recommendations would not be out of date when additional studies appear in the literature.


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

This article was commissioned and sponsored by AbbVie PTy Ltd. Mascot, which has no control over editorial content. The content is entirely independent and based on published studies and the speakers’ opinions and the views expressed are not necessarily those of AbbVie PTy Ltd. Please consult the full Product Information for any medications mentioned in this article at prescribing. Treatment decisions based on these data are the full responsibility of the prescribing physician. AU-HUMS-2016-41.

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