> PsA

Treatment of Psoriatic Arthritis

Based on guidelines from the American College of Rheumatology.

Initial Treatment

In OSM- and other treatment–naive patients with active PsA, treat with a TNFi biologic over an OSM.

Conditional recommendation

Low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with a TNFi biologic over an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with a TNFi biologic over an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with an OSM over an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with an OSM over an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with MTX over NSAIDs.

Conditional recommendation

Very low quality evidence

In OSM- and other treatment–naive patients with active PsA, treat with an IL-17i biologic over an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

Active PsA

On OSM

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic over a different OSM.

Conditional recommendation

Moderate quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic over an IL-17i biologic.

Conditional recommendation

Moderate quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic over an IL-12/23i biologic.

Conditional recommendation

Moderate quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic over abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic over tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-17i over a different OSM.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-17i biologic over an IL-12/23i biologic.

Conditional recommendation

Moderate quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-17i biologic over abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-17i biologic over tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-12/23i biologic over a different OSM.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-12/23i biologic over abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-12/23i biologic over tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, add apremilast to current OSM therapy over switching to apremilast.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to another OSM (except apremilast) over adding another OSM (except apremilast) to current treatment.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to a TNFi biologic monotherapy over MTX and a TNFi biologic combination therapy.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-17i biologic monotherapy over MTX and an IL-17i biologic combination therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an OSM, switch to an IL-12/23i biologic monotherapy over MTX and an IL-12/23i biologic combination therapy.

Conditional recommendation

Very low quality evidence

On TNFi +/- MTX

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic over switching to an IL-17i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic over switching to an IL-12/23i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic over switching to abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic over switching to tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic (with or without MTX) over adding MTX to the same TNFi biologic monotherapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-17i biologic over switching to an IL-12/23i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-17i biologic over abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-17i biologic over tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-12/23i biologic over abatacept.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-12/23i biologic over tofacitinib.

Conditional recommendation

Low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to a different TNFi biologic monotherapy over switching to a different TNFi biologic and MTX combination therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-17i biologic monotherapy over switching to an IL-17i biologic and MTX combination therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic monotherapy, switch to an IL-12/23i biologic monotherapy over switching to an IL-12/23i biologic and MTX combination therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy, switch to a different TNFi biologic + MTX over switching to a different TNFi biologic monotherapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy, switch to an IL-17i biologic monotherapy over an IL-17i biologic and MTX combination therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy, switch to IL-12/23i biologic monotherapy over IL-12/23i biologic and MTX combination therapy.

Conditional recommendation

Very low quality evidence

On IL17i or IL-12/23i

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy, switch to a TNFi biologic over switching to an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy, switch to a TNFi biologic over switching to a different IL-17i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy, switch to a TNFi biologic over adding MTX to an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy, switch to an IL-12/23i biologic over switching to a different IL-17i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy, switch to an IL-12/23i biologic over adding MTX to an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-12/23i biologic monotherapy, switch to a TNFi biologic over switching to an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-12/23i biologic monotherapy, switch to a TNFi biologic over adding MTX to an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA despite treatment with an IL-12/23i biologic monotherapy, switch to an IL-17i biologic over adding MTX to an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

Treat-to-Target, Active Axial Disease, etc

In adult patients with active PsA, use a treat-to-target strategy over not following a treat-to-target strategy.

Conditional recommendation

Low quality evidence

In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs, switch to a TNFi biologic over switching to an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs, switch to a TNFi biologic over switching to an IL-17i biologic.

Conditional recommendation

Very low quality evidence

In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs, switch to an IL-17i biologic over switching to an IL-12/23i.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and predominant enthesitis who are both OSM- and biologic treatment-naive, start oral NSAIDs over an OSM (specifically apremilast).

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and predominant enthesitis who are both OSM- and biologic treatment-naive, start a TNFi biologic over an OSM (specifically apremilast).

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and predominant enthesitis who are both OSM- and biologic treatment-naive, start tofacitinib over an OSM (specifically apremilast).

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to a TNFi biologic over an IL-17i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to a TNFi biologic over an IL-12/23i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to a TNFi biologic over switching to another OSM.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to an IL-17i biologic over an IL-12/23i biologic.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to an IL-17i biologic over switching to another OSM.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and predominant enthesitis despite treatment with OSM, switch to an IL-12/23i biologic over switching to another OSM.

Conditional recommendation

Low quality evidence

In adult patients with active PsA and concomitant active IBD who are both OSM- and biologic treatment–naive, start a monoclonal antibody TNFi biologic over an OSM.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and concomitant active IBD despite treatment with an OSM, switch to a monoclonal antibody TNFi biologic over a TNFi biologic soluble receptor biologic (i.e., etanercept).

Strong recommendation

Moderate quality evidence

In adult patients with active PsA and concomitant active IBD despite treatment with an OSM, switch to a TNFi monoclonal antibody biologic over an IL-17i biologic.

Strong recommendation

Moderate quality evidence

In adult patients with active PsA and concomitant active IBD despite treatment with an OSM, switch to a TNFi biologic monoclonal antibody biologic over an IL-12/23i biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and concomitant active IBD despite treatment with an OSM, switch to an IL-12/23i biologic over switching to an IL-17i biologic.

Strong recommendation

Moderate quality evidence

Comorbidities, Vaccination, Non-drug Tx

Comorbidities

In adult patients with active PsA and diabetes who are both OSM- and biologic treatment–naive, start an OSM other than MTX over a TNFi biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and frequent serious infections who are both OSM- and biologic treatment–naive, start an OSM over a TNFi biologic.

Strong recommendation

Moderate quality evidence

In adult patients with active PsA and frequent serious infections who are both OSM- and biologic treatment–naive, start an IL-12/23i biologic over a TNFi biologic.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA and frequent serious infections who are both OSM- and biologic treatment–naive, start an IL-17i biologic over a TNFi biologic.

Conditional recommendation

Very low quality evidence

Vaccination

In adult patients with active PsA needing vaccinations, start the biologic and administer inactivated vaccines over delaying the start of biologic to administer inactivated vaccines.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA needing vaccinations, delay the start of biologic to administer live attenuated vaccines over starting the biologic and administering live attenuated vaccines.

Conditional recommendation

Very low quality evidence

Nonpharmacologic Intervention

In adult patients with active PsA, recommend exercise over no exercise.

Conditional recommendation

Low quality evidence

In adult patients with active PsA, recommend low-impact exercise (e.g., tai chi, yoga, swimming) over high-impact exercise (e.g., running).

Conditional recommendation

Very low quality evidence

In adult patients with active PsA, recommend physical therapy over no physical therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA, recommend occupational therapy over no occupational therapy.

Conditional recommendation

Low quality evidence

In adult patients with active PsA, recommend weight loss over no weight loss for patients who are overweight/obese.

Conditional recommendation

Low quality evidence

In adult patients with active PsA, recommend massage therapy over no massage therapy.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA, recommend acupuncture over no acupuncture.

Conditional recommendation

Very low quality evidence

In adult patients with active PsA, recommend smoking cessation over no smoking cessation.

Strong recommendation

Moderate quality evidence

What do the icons mean?

How strong is the ACR's recommendation?

Strong recommendation

Intervention's desirable effects clearly outweigh undesirable effects.

Moderate recommendation

Further research likely to impact confidence in estimate of effect.

Conditional recommendation

Uncertainty in tradeoffs between desirable & undesirable effects of intervention.

High quality evidence

Further research unlikely to change guideline authors' confidence in estimate of effect.

Moderate quality evidence

Further research likely to impact confidence in estimate of effect.

Low quality evidence

Further research expected to have important impact in confidence in estimate of effect.

Very low quality evidence

Effect is very uncertain.

Literature

Original/Primary Reference

Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2018.

Calc Function

Initial Treatment

Active PsA

Comorbidities, Vaccination, Non-drug Tx