Pharmacological Management of Psoriatic Arthritis
Pharmacological Management of Psoriatic Arthritis
Background Psoriatic arthritis (PsA) is a clinically heterogeneous disease. Clear consensual treatment guidance focused on the musculoskeletal manifestations of PsA would be advantageous. The authors present European League Against Rheumatism (EULAR) recommendations for the treatment of PsA with systemic or local (non-topical) symptomatic and disease-modifying antirheumatic drugs (DMARD).
Methods The recommendations are based on evidence from systematic literature reviews performed for non-steroidal anti-inflammatory drugs (NSAID), glucocorticoids, synthetic DMARD and biological DMARD. This evidence was discussed, summarised and recommendations were formulated by a task force comprising 35 representatives, and providing levels of evidence, strength of recommendations and levels of agreement.
Results Ten recommendations were developed for treatment from NSAID through synthetic DMARD to biological agents, accounting for articular and extra-articular manifestations of PsA. Five overarching principles and a research agenda were defined.
Conclusion These recommendations are intended to provide rheumatologists, patients and other stakeholders with a consensus on the pharmacological treatment of PsA and strategies to reach optimal outcomes, based on combining evidence and expert opinion. The research agenda informs directions within EULAR and other communities interested in PsA.
The treatment of psoriatic arthritis (PsA) has changed dramatically over recent years, despite the lack of sufficient knowledge on aetiology and detailed pathogenesis. Observations that pro-inflammatory cytokines may play important pathogenetic roles have led to the evaluation of novel therapies; indeed, new synthetic and biological disease-modifying antirheumatic drugs (DMARD) are widely used, with further treatment options anticipated in the near future. While psoriatic skin and joint disease have many facets in common, the pathways leading to their expression may differ, exemplified in the frequent distinct efficacy of various therapies on skin and joint disease (eg, phototherapy, fumaric acid or alefacept). PsA in itself is heterogeneous by virtue of its broad phenotypes of joint involvement (peripheral and spinal), but also its spectrum of extra-articular manifestations, which—aside from skin and nails—comprise dactylitis and enthesopathy.
The complexity of PsA and the relative paucity of randomised controlled clinical studies, let alone strategic trials, contrasts with the situation in rheumatoid arthritis (RA), another chronic and destructive inflammatory joint disease. There are data on the usefulness of synthetic DMARD as well as the efficacy of biological DMARD, particularly tumour necrosis factor (TNF) inhibitors in PsA, and there exist general recommendations for the use of biological agents. Recently, recommendations for PsA treatment were presented by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). These recommendations are comprehensive, with a special focus on skin disease, providing an initial treatment guidance set. However, clinicians can benefit from concise, easy to follow guidance on the optimal use of available therapies and clear treatment strategies for PsA.
Among other aspects, the efficacy of synthetic DMARD and the role of glucocorticoids remain under debate, and combination therapy of synthetic DMARD or synthetic DMARD with biological agents is relatively underresearched. Moreover, even disease activity assessment of PsA is under scrutiny, given that the measures used in clinical trials are mostly 'borrowed' from RA with further methods under evaluation. Furthermore, therapeutic targets require definition.
All of these reasons, as well as more recent insights, provided a rationale for the development of European League Against Rheumatism (EULAR) recommendations for the management of PsA. Rheumatologists require evidence-based guidance for the treatment of PsA with regard to synthetic and biological therapies, including the definition of treatment targets and assessment tools.
To address the set task, EULAR convened a group of experts to produce evidence-based recommendations for the management of PsA with non-topical pharmacological therapies on the basis of the EULAR standard operating procedures, and to develop a research agenda for future activities.
Abstract and Introduction
Abstract
Background Psoriatic arthritis (PsA) is a clinically heterogeneous disease. Clear consensual treatment guidance focused on the musculoskeletal manifestations of PsA would be advantageous. The authors present European League Against Rheumatism (EULAR) recommendations for the treatment of PsA with systemic or local (non-topical) symptomatic and disease-modifying antirheumatic drugs (DMARD).
Methods The recommendations are based on evidence from systematic literature reviews performed for non-steroidal anti-inflammatory drugs (NSAID), glucocorticoids, synthetic DMARD and biological DMARD. This evidence was discussed, summarised and recommendations were formulated by a task force comprising 35 representatives, and providing levels of evidence, strength of recommendations and levels of agreement.
Results Ten recommendations were developed for treatment from NSAID through synthetic DMARD to biological agents, accounting for articular and extra-articular manifestations of PsA. Five overarching principles and a research agenda were defined.
Conclusion These recommendations are intended to provide rheumatologists, patients and other stakeholders with a consensus on the pharmacological treatment of PsA and strategies to reach optimal outcomes, based on combining evidence and expert opinion. The research agenda informs directions within EULAR and other communities interested in PsA.
Introduction
The treatment of psoriatic arthritis (PsA) has changed dramatically over recent years, despite the lack of sufficient knowledge on aetiology and detailed pathogenesis. Observations that pro-inflammatory cytokines may play important pathogenetic roles have led to the evaluation of novel therapies; indeed, new synthetic and biological disease-modifying antirheumatic drugs (DMARD) are widely used, with further treatment options anticipated in the near future. While psoriatic skin and joint disease have many facets in common, the pathways leading to their expression may differ, exemplified in the frequent distinct efficacy of various therapies on skin and joint disease (eg, phototherapy, fumaric acid or alefacept). PsA in itself is heterogeneous by virtue of its broad phenotypes of joint involvement (peripheral and spinal), but also its spectrum of extra-articular manifestations, which—aside from skin and nails—comprise dactylitis and enthesopathy.
The complexity of PsA and the relative paucity of randomised controlled clinical studies, let alone strategic trials, contrasts with the situation in rheumatoid arthritis (RA), another chronic and destructive inflammatory joint disease. There are data on the usefulness of synthetic DMARD as well as the efficacy of biological DMARD, particularly tumour necrosis factor (TNF) inhibitors in PsA, and there exist general recommendations for the use of biological agents. Recently, recommendations for PsA treatment were presented by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). These recommendations are comprehensive, with a special focus on skin disease, providing an initial treatment guidance set. However, clinicians can benefit from concise, easy to follow guidance on the optimal use of available therapies and clear treatment strategies for PsA.
Among other aspects, the efficacy of synthetic DMARD and the role of glucocorticoids remain under debate, and combination therapy of synthetic DMARD or synthetic DMARD with biological agents is relatively underresearched. Moreover, even disease activity assessment of PsA is under scrutiny, given that the measures used in clinical trials are mostly 'borrowed' from RA with further methods under evaluation. Furthermore, therapeutic targets require definition.
All of these reasons, as well as more recent insights, provided a rationale for the development of European League Against Rheumatism (EULAR) recommendations for the management of PsA. Rheumatologists require evidence-based guidance for the treatment of PsA with regard to synthetic and biological therapies, including the definition of treatment targets and assessment tools.
To address the set task, EULAR convened a group of experts to produce evidence-based recommendations for the management of PsA with non-topical pharmacological therapies on the basis of the EULAR standard operating procedures, and to develop a research agenda for future activities.
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