Practice Guideline

. 2020 Jun;79(6):700-712.

doi: 10.1136/annrheumdis-2020-217159.

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update

Laure Gossec^{1

2}, Xenofon Baraliakos³, Andreas Kerschbaumer⁴, Maarten de Wit⁵, Iain McInnes⁶, Maxime Dougados⁷, Jette Primdahl^{8

9}, Dennis G McGonagle^{10

11}, Daniel Aletaha¹², Andra Balanescu¹³, Peter V Balint¹⁴, Heidi Bertheussen¹⁵, Wolf-Henning Boehncke¹⁶, Gerd R Burmester¹⁷, Juan D Canete¹⁸, Nemanja S Damjanov¹⁹, Tue Wenzel Kragstrup^{20

21}, Tore K Kvien²², Robert B M Landewé^{23

24}, Rik Jozef Urbain Lories^{25

26}, Helena Marzo-Ortega^{10

11}, Denis Poddubnyy^{27

28}, Santiago Andres Rodrigues Manica^{29

30}, Georg Schett³¹, Douglas J Veale³², Filip E Van den Bosch³³, Désirée van der Heijde^{22

34}, Josef S Smolen^{35

36}

Affiliations

¹ Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France laure.gossec@gmail.com.
² APHP.Sorbonne Universite, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France.
³ Ruhr-Universität Bochum, Rheumazentrum Ruhrgebiet, Herne, Germany.
⁴ Division of Rheumatology, Department of Medicine 3; 2nd Department of Medicine, Hietzing Hospital, Medical University of Vienna, Vienna, Austria.
⁵ EULAR, Zurich, Switzerland.
⁶ Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
⁷ Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France.
⁸ Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.
⁹ Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
¹⁰ LTHT, Leeds NIHR Biomedical Research Centre, Leeds, UK.
¹¹ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹² Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
¹³ Research Center of Rheumatic Diseases, Sf Maria Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
¹⁴ 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary.
¹⁵ Patient Research Partner, EULAR, Oslo, Norway.
¹⁶ Dermatology, University Hospitals of Geneva, Geneva, Switzerland.
¹⁷ Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany.
¹⁸ Arthritis Unit, Department of Rheumatology and IDIBAPS, Hospital Clinic, Barcelona, Spain.
¹⁹ Institute of Rheumatology, Belgrade University School of Medicine, Belgrade, Serbia.
²⁰ Department of Biomedicine, Aarhus University, Aarhus C, Denmark.
²¹ Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark.
²² Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
²³ Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.
²⁴ Rheumatology, Zuyderland MC, Heerlen, The Netherlands.
²⁵ Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium.
²⁶ Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.
²⁷ Department of Rheumatology, Infectious Diseases and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany.
²⁸ Epidemiology, German Rheumatism Research Center Berlin, Berlin, Germany.
²⁹ Rheumatology, Hospital de Egas Moniz, Lisboa, Portugal.
³⁰ Universidade Nova de Lisboa Centro de Estudos de Doencas Cronicas, Lisboa, Portugal.
³¹ Internal Medicine, University of Erlangen-Nuremberg, Erlangen, Germany.
³² Centre for Arthritis and Rheumatic Disease, Dublin Academic Medical Centre, St Vincent's University Hospital, Dublin, Ireland.
³³ Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium.
³⁴ Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
³⁵ Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Wien, Austria.
³⁶ 2nd Department of Medicine, Hietzing Hospital, Vienna, Wien, Austria.

PMID: 32434812
PMCID: PMC7286048
DOI: 10.1136/annrheumdis-2020-217159

Practice Guideline

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update

Laure Gossec et al. Ann Rheum Dis. 2020 Jun.

. 2020 Jun;79(6):700-712.

doi: 10.1136/annrheumdis-2020-217159.

Authors

Affiliations

¹ Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France laure.gossec@gmail.com.
² APHP.Sorbonne Universite, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France.
³ Ruhr-Universität Bochum, Rheumazentrum Ruhrgebiet, Herne, Germany.
⁴ Division of Rheumatology, Department of Medicine 3; 2nd Department of Medicine, Hietzing Hospital, Medical University of Vienna, Vienna, Austria.
⁵ EULAR, Zurich, Switzerland.
⁶ Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
⁷ Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France.
⁸ Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.
⁹ Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
¹⁰ LTHT, Leeds NIHR Biomedical Research Centre, Leeds, UK.
¹¹ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹² Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
¹³ Research Center of Rheumatic Diseases, Sf Maria Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
¹⁴ 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary.
¹⁵ Patient Research Partner, EULAR, Oslo, Norway.
¹⁶ Dermatology, University Hospitals of Geneva, Geneva, Switzerland.
¹⁷ Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany.
¹⁸ Arthritis Unit, Department of Rheumatology and IDIBAPS, Hospital Clinic, Barcelona, Spain.
¹⁹ Institute of Rheumatology, Belgrade University School of Medicine, Belgrade, Serbia.
²⁰ Department of Biomedicine, Aarhus University, Aarhus C, Denmark.
²¹ Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark.
²² Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
²³ Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.
²⁴ Rheumatology, Zuyderland MC, Heerlen, The Netherlands.
²⁵ Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Flanders, Belgium.
²⁶ Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.
²⁷ Department of Rheumatology, Infectious Diseases and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany.
²⁸ Epidemiology, German Rheumatism Research Center Berlin, Berlin, Germany.
²⁹ Rheumatology, Hospital de Egas Moniz, Lisboa, Portugal.
³⁰ Universidade Nova de Lisboa Centro de Estudos de Doencas Cronicas, Lisboa, Portugal.
³¹ Internal Medicine, University of Erlangen-Nuremberg, Erlangen, Germany.
³² Centre for Arthritis and Rheumatic Disease, Dublin Academic Medical Centre, St Vincent's University Hospital, Dublin, Ireland.
³³ Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium.
³⁴ Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
³⁵ Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Wien, Austria.
³⁶ 2nd Department of Medicine, Hietzing Hospital, Vienna, Wien, Austria.

PMID: 32434812
PMCID: PMC7286048
DOI: 10.1136/annrheumdis-2020-217159

Abstract

Objective: To update the European League Against Rheumatism (EULAR) recommendations for the pharmacological treatment of psoriatic arthritis (PsA).

Methods: According to the EULAR standardised operating procedures, a systematic literature review was followed by a consensus meeting to develop this update involving 28 international taskforce members in May 2019. Levels of evidence and strengths of recommendations were determined.

Results: The updated recommendations comprise 6 overarching principles and 12 recommendations. The overarching principles address the nature of PsA and diversity of both musculoskeletal and non-musculoskeletal manifestations; the need for collaborative management and shared decision-making is highlighted. The recommendations provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs and local glucocorticoid injections are proposed as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis accompanied by factors such as dactylitis or joint damage, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drugs (bDMARDs) targeting tumour necrosis factor (TNF), interleukin (IL)-17A or IL-12/23 should be initiated, taking into account skin involvement if relevant. If axial disease predominates, a TNF inhibitor or IL-17A inhibitor should be started as first-line disease-modifying antirheumatic drug. Use of Janus kinase inhibitors is addressed primarily after bDMARD failure. Phosphodiesterase-4 inhibition is proposed for patients in whom these other drugs are inappropriate, generally in the context of mild disease. Drug switches and tapering in sustained remission are addressed.

Conclusion: These recommendations provide stakeholders with an updated consensus on the pharmacological management of PsA, based on a combination of evidence and expert opinion.

Keywords: DMARDs (biologic); psoriatic arthritis; treatment.

PubMed Disclaimer

Conflict of interest statement

Competing interests: LG: AbbVie, Biogen, Celgene, Janssen, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB. XB: AbbVie, Amgen, BMS, Celgene, Chugai, Hexal, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Sandoz, UCB. AK: Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Merck Sharp and Dohme, Novartis, Pfizer. MdW: Through Stichting Tools from AbbVie, BMS, Celgene, Eli Lilly, Janssen-Cilag, Novartis, Pfizer, Roche. IM: AbbVie, BMS, Lilly, Novartis, Celgene, Gilead, Janssen, Boehringer, UCB, Pfizer. MD: AbbVie, BMS, Janssen, Lilly, Novartis, Merck, Pfizer, UCB. JP: BMS, Pfizer. DGM: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB. DA: AbbVie, Amgen, Gilead, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, Sobi. AB: AbbVie, Amgen, AstraZeneca, Angelini, AlfaSigma, BMS, Berlin-Chemie, Egis, Ewopharma, GSK, Lilly, Mylan, MSD, Novartis, Pfizer, Roche, Sandoz, Sanofi, Teva, UCB, Zentiva. PVB: AbbVie, Celgene, Lilly, MSD, Novartis, Pfizer, Richter. HB: Pfizer. W-HB: AbbVie, Almirall, BMS, Celgene, Leo, Lilly, Novartis, Pfizer, UCB. GRB: AbbVie, Celgene, Lilly, MSD, Novartis, Pfizer. JDC: Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, UCB. NSD: AbbVie, Boehringer Ingelheim, Gedeon Richter, Lilly, Novartis, Pfizer, Roche. TWK: Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer, UCB. TKK: AbbVie, Amgen, Biogen, BMS, Celltrion, Egis, Eli Lilly, Ewopharma, Hikma, Hospira/Pfizer, MSD, Mylan, Orion Pharma, Roche, Sandoz, Sanofi, UCB. RBML: AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB. RJUL is Director of Rheumatology Consultancy; AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB. HM-O: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB. DP: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. SARM: Janssen, MSD, Novartis. GS: AbbVie, BMS, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, UCB. DJV: AbbVie, Biogen, Boehringer Ingelheim, HealthBeacon, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. FEVdB: AbbVie, Celgene, Eli Lilly, Galapagos/Gilead, Janssen, Merck, Novartis, Pfizer, UCB. DvdH: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology. JSS: grants to institution from AbbVie, AstraZeneca, Janssen, Lilly, Merck Sharp & Dohme, Pfizer and Roche; speaker for AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO Pharma, Janssen, Lilly, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi and UCB.

Figures

**Figure 1**
The EULAR 2019 algorithm for treatment of PsA with pharmacological non-topical treatments. bDMARDs, biological disease-modifying antirheumatic drugs; EULAR, European League Against Rheumatism; IL-12/23i, interleukin-12/23 inhibitor; IL-17i, interleukin-17 inhibitor; JAKi, Janus kinase inhibitor; NSAIDs, non-steroidal anti-inflammatory drugs; PDE4i, phosphodiesterase-4 inhibitor; PsA, psoriatic arthritis; TNFi, tumour necrosis factor inhibitor.

See this image and copyright information in PMC

Comment in

Response to: 'Comment on: 'EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update' by Gossec et al' by Wei et al.
Gossec L, Baraliakos X, McInnes I, Kerschbaumer A, de Wit M, Dougados M, Primdahl J, van der Heijde D, Smolen JS. Gossec L, et al. Ann Rheum Dis. 2022 Aug;81(8):e139. doi: 10.1136/annrheumdis-2020-218456. Epub 2020 Sep 1. Ann Rheum Dis. 2022. PMID: 32873555 No abstract available.
Comment on: 'EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update' by Gossec et al.
Wei CY, Lee YH, Wei JCC. Wei CY, et al. Ann Rheum Dis. 2022 Aug;81(8):e138. doi: 10.1136/annrheumdis-2020-218385. Epub 2020 Sep 1. Ann Rheum Dis. 2022. PMID: 32873556 No abstract available.

References

1. Kerschbaumer A, Smolen JS, Dougados M, et al. . Pharmacological treatment of psoriatic arthritis: a systematic literature research for the 2019 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2016. 10.1136/annrheumdis-2015-208466 - DOI - PubMed
1. Fernández‐Carballido C, Martín‐Martínez MA, García‐Gómez C, et al. . Impact of comorbidity on physical function in patients with ankylosing spondylitis and psoriatic arthritis attending rheumatology clinics. Results from the CAR diovascular in rheu MA tology (CARMA) study. Arthritis Care Res. - PMC - PubMed
1. Rodriguez-Moreno J, Bonet M, Del Blanco-Barnusell J, et al. . Mutilating/resorptive arthritis. A study of 24 patients in a series of 360 patients with psoriatic arthritis. Reumatol Clin 2013;9:38–41. 10.1016/j.reuma.2012.06.015 - DOI - PubMed
1. Ferguson LD, Siebert S, McInnes IB, et al. . Cardiometabolic comorbidities in RA and PsA: lessons learned and future directions. Nat Rev Rheumatol 2019;15:461–74. 10.1038/s41584-019-0256-0 - DOI - PubMed
1. Gudu T, Etcheto A, de Wit M, et al. . Fatigue in psoriatic arthritis - a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine 2016;83:439–43. 10.1016/j.jbspin.2015.07.017 - DOI - PubMed

Publication types

Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Substances

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

LinkOut - more resources

Full Text Sources
Medical
- ClinicalTrials.gov
- MedlinePlus Health Information
Research Materials
- NCI CPTC Antibody Characterization Program
Miscellaneous
- NCI CPTAC Assay Portal

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update

Affiliations

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

References

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Medical

Research Materials

Miscellaneous