Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021

Abstract

Since the second version of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations were published in 2015, therapeutic options for psoriatic arthritis (PsA) have advanced considerably. This work reviews the literature since the previous recommendations (data published 2013-2020, including conference presentations between 2017 and 2020) and reports high-quality, evidence-based, domain-focused recommendations for medication selection in PsA developed by GRAPPA clinicians and patient research partners. The overarching principles for the management of adults with PsA were updated by consensus. Principles considering biosimilars and tapering of therapy were added, and the research agenda was revised. Literature searches covered treatments for the key domains of PsA: peripheral arthritis, axial disease, enthesitis, dactylitis, and skin and nail psoriasis; additional searches were performed for PsA-related conditions (uveitis and inflammatory bowel disease) and comorbidities. Individual subcommittees used a GRADE-informed approach, taking into account the quality of evidence for therapies, to generate recommendations for each of these domains, which were incorporated into an overall schema. Choice of therapy for an individual should ideally address all disease domains active in that patient, supporting shared decision-making. As safety issues often affect potential therapeutic choices, additional consideration was given to relevant comorbidities. These GRAPPA treatment recommendations provide up-to-date, evidence-based guidance on PsA management for clinicians and people with PsA.

Fig. 1. Flowcharts representing the results of the evidence searches.

Systematic literature reviews were undertaken to identify evidence related to medications for psoriatic arthritis (PsA) published since 2013, to inform the 2021 update of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations for PsA. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagrams showing the results of (a) the main search for intervention randomized controlled trials (RCTs) for PsA (19 February 2013 to 28 August 2020) and additional searches related to (b) prognosis and phenotype of individuals with PsA and related conditions (inflammatory bowel disease (IBD) and uveitis) (19 February 2013 to 12 November 2020) and (c) screening of comorbidities and related conditions in patients with PsA (19 February 2013 to 10 November 2020). The detailed search strategies can be found in Supplementary Tables 2–6.

Fig. 2. GRAPPA 2021 treatment schema.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2021 treatment recommendations for psoriatic arthritis (PsA) use a domain-based approach, but, considering that most patients present with disease in multiple domains, this treatment schema combines the recommendations for each domain to guide therapeutic decisions. Disease activity should be assessed in each of the domains and consideration given to comorbidities, previous therapies and patient preference. Standard ‘step-up’ approaches, as well as expedited treatment routes, are indicated. Treatment efficacy and tolerability should be re-evaluated periodically and treatment adjusted as appropriate. The order of the products in the boxes is sorted by mechanism of action and does not reflect guidance on relative efficacy or suggested usage. Bold text indicates a strong recommendation, standard text a conditional recommendation. The asterisks indicate a conditional recommendation based on data from abstracts only. bDMARD, biologic DMARD; CTLA4-Ig, CTLA4–immunoglobulin fusion protein; csDMARD, conventional synthetic DMARD; ETN, etanercept; GC, glucocorticoid; IBD, inflammatory bowel disease; JAKi, Janus kinase inhibitor; MTX, methotrexate; PDE4i, phosphodiesterase 4 inhibitor; TNFi, TNF inhibitor.