The 2023 European Alliance of Associations for Rheumatology (EULAR) recommendations for psoriatic arthritis (PsA) provide an evidence-based treatment strategy, prioritizing conventional and biological disease-modifying antirheumatic drugs, including biosimilars, tailored to disease manifestations, with an emphasis on safety, cost-effectiveness, and patient-centered care.
The updated 2023 recommendations from the European Alliance of Associations for Rheumatology (EULAR) for psoriatic arthritis (PsA) provided a comprehensive and practical treatment strategy, integrating all current drugs and prioritizing conventional and biological disease-modifying antirheumatic drugs (DMARDs), including biosimilars, based on disease characteristics, with specific guidance on drug choices for different PsA manifestations.1
“The updated 2023 recommendations should be helpful to clinicians but also to health professionals and patients when discussing treatment options. They can also be helpful to promote access to optimal care. As new data become available and new drugs are authorized in PsA, these recommendations should be again updated,” the authors wrote.
The new recommendations, published in Annals of Rheumatic Diseases, were created to update the EULAR 2019 recommendations for the pharmacological treatment of PsA in response to the introduction of new therapeutic options—including 10 adalimumab biosimilars, 3 etanercept biosimilars, and 4 infliximab biosimilars approved by the European Medicines Agency for PsA—and additional data on the efficacy and safety of existing drugs.2
Recent advances in PsA management include tools for earlier diagnosis, targeted treatment strategies, and a holistic approach to comorbidities, with an expanded range of pharmacological options now available, including conventional, biological, and targeted synthetic DMARDs. The updated EULAR recommendations focus on non-topical pharmacological management, particularly for musculoskeletal symptoms, while also considering skin involvement and comorbidities in treatment decisions.
The update process followed EULAR's standardized procedures, beginning with the selection of a diverse taskforce, including new members and representatives from various regions and specialties. The process involved a systematic literature review (SLR) to address predefined questions on PsA treatments, followed by a consensus-driven approach where the taskforce—composed of rheumatologists, dermatologists, infectious disease specialists, patient partners, and health professionals—met to discuss and vote on the recommendations.
According to the report, the recommendations were based on a combination of evidence, expert experience, and consensus, with levels of evidence and grades of recommendation determined according to the Oxford Evidence Based System. Final agreement on each recommendation was reached through multiple rounds of voting.
The update included 7 overarching principles (one more than in 2019) and 11 recommendations (1 fewer than in 2019 due to merges), with most principles either revised or reworded, and only 4 recommendations remaining unchanged. Key additions include a new principle emphasizing the importance of considering safety in treatment choices, alongside existing principles that highlight the need for multidisciplinary care, shared decision-making, and tailored treatment approaches considering both musculoskeletal and non-musculoskeletal manifestations of PsA.
The 11 recommendations were:
These recommendations emphasize a treat-to-target strategy, starting with csDMARDs and escalating to bDMARDs or JAKi based on disease severity, response, and patient-specific factors. The recommendations also highlighted the importance of cost-effectiveness, suggesting that less expensive but similarly effective drugs, including biosimilars, should be preferred.
References
1. Gossec L, Kerschbaumer A, Ferreira RJO, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update. Ann Rheum Dis. 2024;83(6):706-719. doi:10.1136/ard-2024-225531
2. Biosimilars approvals. The Center for Biosimilars®. Updated March 22, 2024. Accessed August 15, 2024. https://www.centerforbiosimilars.com/biosimilar-approvals
3. Lembke S, Macfarlane GJ, Jones GT. The worldwide prevalence of psoriatic arthritis-a systematic review and meta-analysis. Rheumatology (Oxford). Published online March 26, 2024. doi:10.1093/rheumatology/keae198
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