New Treatment Guideline for PsA Recommends First-Line Anti-TNF Biologics

This week, the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) released a new treatment guideline for psoriatic arthritis (PsA) that contains evidence-based recommendations on caring for patients with this inflammatory disease.

The guideline was developed using Grading of Recommendations Assessment, Development and Evaluation methodology, and recommendations—many of which are conditional as they were based on low- to very low-quality evidence—were voted on by a panel of rheumatologists, dermatologists, health professionals, and patients.

Among key recommendations of the guideline is a conditional recommendation to use a treat-to-target approach for all patients with active PsA. “Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama at Birmingham, said in a statement. “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.”

Notably, the new guideline also includes a conditional recommendation to use anti—tumor necrosis factor (anti-TNF) therapies as first-line treatment. “The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying [an anti-TNF] biologic first,” said Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and NPF Medical Board member who served as a content expert during the guideline’s development. “This doesn’t hold true once other symptoms and comorbidities are present,” she added, so oral small-molecule drugs can continue to be an option for patients for whom a biologic is inappropriate.

The guideline also includes a strong recommendation for smoking cessation, particularly based on evidence that smoking reduces biologics’ efficacy (in addition to the fact that smoking is well understood to increase mortality, cancer, and heart and lung diseases).

Finally, the guideline makes a strong recommendation for using anti-TNF monoclonal antibodies instead of etanercept, an anti-TNF soluble receptor biologic, in patients who have concomitant inflammatory bowel disease (IBD). This recommendation, made on the basis of moderate-quality evidence that etanercept is less effective than other options in IBD, is accompanied by strong recommendations for patients with concomitant IBD to use an anti-TNF over an interleukin (IL)-17 inhibitor, and to use an IL-12/IL-23 inhibitor rather than an IL-17 inhibitor.