Prioritizing Patient-Centered Care in PsA: Key Insights From the 2023 EULAR Guidelines

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:

1. Aim to achieve remission or low disease activity by regularly assessing disease activity and adjusting therapy accordingly. Treatment should be tailored to the most active disease manifestation.
2. Use non-steroidal anti-inflammatory drugs (NSAIDs) for short-term relief of musculoskeletal symptoms, and consider local glucocorticoid injections as adjunctive therapy. Systemic glucocorticoids should be avoided due to safety concerns, but may be used selectively.
3. In patients with polyarthritis or monoarthritis/oligoarthritis with poor prognostic factors, start a conventional synthetic DMARDs (csDMARD) rapidly, with methotrexate preferred for those with skin involvement.
4. If csDMARDs are ineffective in treating peripheral arthritis, begin therapy with a biologic DMARD (bDMARD). Janus kinase inhibitors (JAKi) may be considered if bDMARDs are not suitable.
5. In patients with peripheral arthritis who do not respond to bDMARDs, a JAKi may be considered, with careful attention to safety.
6. For patients with axial involvement, use NSAIDs first, followed by a bDMARD (tumor necrosis factor inhibitors or IL-17 inhibitors) if NSAIDs fail. Other drugs, such as JAKi, may be considered if bDMARDs are unsuitable.
7. Treat patients with these conditions similarly to those with peripheral arthritis, using local therapies and systemic treatments as necessary. JAKi may be considered after failure of bDMARDs.
8. For patients with significant skin involvement, consider IL-17 or IL-23 inhibitors, especially if initial treatment with csDMARDs or TNF inhibitors is insufficient.
9. Treatment choices should take into account comorbid conditions, patient preferences, and potential side effects, especially regarding cardiovascular risks and infections.
10. Tailor treatment based on the patient's specific disease manifestations and comorbidities, while also considering the safety profile of the treatment options.
11. Continuously assess the patient's response to therapy and adjust treatment as necessary to maintain disease control, considering both efficacy and safety over the long term.

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