Practice Guideline

. 2024 May 15;83(6):706-719.

doi: 10.1136/ard-2024-225531.

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

Laure Gossec^{1

2}, Andreas Kerschbaumer³, Ricardo J O Ferreira^{4

5}, Daniel Aletaha³, Xenofon Baraliakos⁶, Heidi Bertheussen⁷, Wolf-Henning Boehncke⁸, Bente Appel Esbensen^{9

10}, Iain B McInnes¹¹, Dennis McGonagle^{12

13}, Kevin L Winthrop¹⁴, Andra Balanescu¹⁵, Peter V Balint¹⁶, Gerd R Burmester¹⁷, Juan D Cañete^{18

19}, Pascal Claudepierre^{20

21}, Lihi Eder²², Merete Lund Hetland^{23

24}, Annamaria Iagnocco²⁵, Lars Erik Kristensen^{26

27}, Rik Lories^{28

29}, Rubén Queiro^{30

31}, Daniele Mauro³², Helena Marzo-Ortega^{12

13}, Philip J Mease^{33

34}, Peter Nash³⁵, Wendy Wagenaar^{36

37}, Laura Savage³⁸, Georg Schett³⁹, Stephanie J W Shoop-Worrall⁴⁰, Yoshiya Tanaka⁴¹, Filip E Van den Bosch⁴², Annette van der Helm-van Mil⁴³, Alen Zabotti⁴⁴, Désirée van der Heijde⁴³, Josef S Smolen³

Affiliations

¹ INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universite, Paris, France laure.gossec@aphp.fr.
² APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France.
³ Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
⁴ Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher School of Nursing of Lisbon, Lisbon, Portugal.
⁵ Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal.
⁶ Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Herne, Germany.
⁷ EULAR Patient Research Partner, EULAR, Oslo, Norway.
⁸ Dermatology and Venereology, Geneva University Hospitals, Geneva, Switzerland.
⁹ Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark.
¹⁰ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
¹¹ College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
¹² LTHT, NIHR Leeds Biomedical Research Centre, Leeds, UK.
¹³ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹⁴ Division of Infectious Diseases, School of Medicine, School of Public Health, Oregon Health & Science University, Portland, Oregon, USA.
¹⁵ Sf Maria Hospital, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania.
¹⁶ Medical Imaging Centre, Semmelweis University, 3rd Rheumatology Department, National Institute of Musculoskeletal Diseases, Budapest, Hungary.
¹⁷ Department of Rheumatology and Clinical Immunology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹⁸ Arthritis Unit, Department of Rheumatology, Hospital Clínic Barcelona, Barcelona, Spain.
¹⁹ FCRB, IDIBAPS, Barcelona, Spain.
²⁰ Rheumatology, AP-HP, Henri Mondor University Hospital, Creteil, France.
²¹ EA Epiderme, UPEC, Creteil, France.
²² Department of Medicine, University of Toronto, Women's College Hospital, Toronto, Toronto, Canada.
²³ The Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark.
²⁴ Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
²⁵ Academic Rheumatology Centre, Dipartimento Scienze Cliniche Biologiche, Università di Torino - AO Mauriziano Torino, Turin, Italy.
²⁶ The Parker Institute, Bispebjerg, Denmark.
²⁷ Frederiksberg Hospital, Copenhagen University, Copenhagen, Denmark.
²⁸ Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.
²⁹ Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium.
³⁰ Rheumatology, Hospital Universitario Central de Asturias, Oviedo, Spain.
³¹ Translational Immunology Division, Biohealth Research Institute of the Principality of Asturias, Oviedo University School of Medicine, Oviedo, Spain.
³² Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy.
³³ Rheumatology Research, Providence Swedish, Seattle, Washington, USA.
³⁴ University of Washington School of Medicine, Seattle, Washington, USA.
³⁵ School of Medicine, Griffith University, Brisbane, Queensland, Australia.
³⁶ Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands.
³⁷ Young PARE Patient Research Partner, EULAR, Zurich, Switzerland.
³⁸ School of Medicine and Dermatology, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, UK.
³⁹ Department of Internal Medicine 3, Rheumatology and Immunology and Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
⁴⁰ Children and Young Person's Rheumatology Research Programme, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK.
⁴¹ First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.
⁴² Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium.
⁴³ Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
⁴⁴ Department of Medical and Biological Sciences, Azienda sanitaria universitaria Friuli Centrale, Udine, Italy.

PMID: 38499325
PMCID: PMC11103320
DOI: 10.1136/ard-2024-225531

Practice Guideline

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

Laure Gossec et al. Ann Rheum Dis. 2024.

. 2024 May 15;83(6):706-719.

doi: 10.1136/ard-2024-225531.

Authors

Affiliations

¹ INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universite, Paris, France laure.gossec@aphp.fr.
² APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France.
³ Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
⁴ Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher School of Nursing of Lisbon, Lisbon, Portugal.
⁵ Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal.
⁶ Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Herne, Germany.
⁷ EULAR Patient Research Partner, EULAR, Oslo, Norway.
⁸ Dermatology and Venereology, Geneva University Hospitals, Geneva, Switzerland.
⁹ Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark.
¹⁰ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
¹¹ College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
¹² LTHT, NIHR Leeds Biomedical Research Centre, Leeds, UK.
¹³ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹⁴ Division of Infectious Diseases, School of Medicine, School of Public Health, Oregon Health & Science University, Portland, Oregon, USA.
¹⁵ Sf Maria Hospital, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania.
¹⁶ Medical Imaging Centre, Semmelweis University, 3rd Rheumatology Department, National Institute of Musculoskeletal Diseases, Budapest, Hungary.
¹⁷ Department of Rheumatology and Clinical Immunology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹⁸ Arthritis Unit, Department of Rheumatology, Hospital Clínic Barcelona, Barcelona, Spain.
¹⁹ FCRB, IDIBAPS, Barcelona, Spain.
²⁰ Rheumatology, AP-HP, Henri Mondor University Hospital, Creteil, France.
²¹ EA Epiderme, UPEC, Creteil, France.
²² Department of Medicine, University of Toronto, Women's College Hospital, Toronto, Toronto, Canada.
²³ The Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark.
²⁴ Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
²⁵ Academic Rheumatology Centre, Dipartimento Scienze Cliniche Biologiche, Università di Torino - AO Mauriziano Torino, Turin, Italy.
²⁶ The Parker Institute, Bispebjerg, Denmark.
²⁷ Frederiksberg Hospital, Copenhagen University, Copenhagen, Denmark.
²⁸ Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.
²⁹ Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium.
³⁰ Rheumatology, Hospital Universitario Central de Asturias, Oviedo, Spain.
³¹ Translational Immunology Division, Biohealth Research Institute of the Principality of Asturias, Oviedo University School of Medicine, Oviedo, Spain.
³² Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy.
³³ Rheumatology Research, Providence Swedish, Seattle, Washington, USA.
³⁴ University of Washington School of Medicine, Seattle, Washington, USA.
³⁵ School of Medicine, Griffith University, Brisbane, Queensland, Australia.
³⁶ Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands.
³⁷ Young PARE Patient Research Partner, EULAR, Zurich, Switzerland.
³⁸ School of Medicine and Dermatology, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, UK.
³⁹ Department of Internal Medicine 3, Rheumatology and Immunology and Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
⁴⁰ Children and Young Person's Rheumatology Research Programme, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK.
⁴¹ First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.
⁴² Department of Internal Medicine and Pediatrics, VIB Center for Inflammation Research, Ghent University, Gent, Belgium.
⁴³ Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
⁴⁴ Department of Medical and Biological Sciences, Azienda sanitaria universitaria Friuli Centrale, Udine, Italy.

PMID: 38499325
PMCID: PMC11103320
DOI: 10.1136/ard-2024-225531

Abstract

Objective: New modes of action and more data on the efficacy and safety of existing drugs in psoriatic arthritis (PsA) required an update of the EULAR 2019 recommendations for the pharmacological treatment of PsA.

Methods: Following EULAR standardised operating procedures, the process included a systematic literature review and a consensus meeting of 36 international experts in April 2023. Levels of evidence and grades of recommendations were determined.

Results: The updated recommendations comprise 7 overarching principles and 11 recommendations, and provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs should be used in monotherapy only for mild PsA and in the short term; oral glucocorticoids are not recommended. In patients with peripheral arthritis, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended and methotrexate preferred. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drug (bDMARD) should be initiated, without preference among modes of action. Relevant skin psoriasis should orient towards bDMARDs targeting interleukin (IL)-23p40, IL-23p19, IL-17A and IL-17A/F inhibitors. In case of predominant axial or entheseal disease, an algorithm is also proposed. Use of Janus kinase inhibitors is proposed primarily after bDMARD failure, taking relevant risk factors into account, or in case bDMARDs are not an appropriate choice. Inflammatory bowel disease and uveitis, if present, should influence drug choices, with monoclonal tumour necrosis factor inhibitors proposed. Drug switches and tapering in sustained remission are also addressed.

Conclusion: These updated recommendations integrate all currently available drugs in a practical and progressive approach, which will be helpful in the pharmacological management of PsA.

Keywords: Biological Therapy; Biosimilar Pharmaceuticals; Psoriatic Arthritis; Treatment.

© European Alliance of Associations for Rheumatology, EULAR 2024. Re-use permitted under CC BY-NC-ND. No commercial re-use. No derivatives. See rights and permissions. Published by BMJ on behalf of EULAR.

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Conflict of interest statement

Competing interests: No support to any author for the present work. Outside the submitted work: LG: research grants: AbbVie, Biogen, Lilly, Novartis, UCB; consulting fees: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, MSD, Novartis, Pfizer, UCB; non-financial support: AbbVie, Amgen, Galapagos, Janssen, MSD, Novartis, Pfizer, UCB; membership on an entity’s Board of Directors or advisory committees: EULAR Treasurer. AK: speakers bureau, consultancy: AbbVie, Amgen, Galapagos, Janssen, Eli Lilly, MSD, Novartis, Pfizer, UCB. RJOF: research grants: Medac, Lilly; consulting fees: Sanofi. DA: research grants: Galapagos, Lilly; consulting fees: AbbVie, Gilead, Janssen, Lilly, Merck, Novartis, Sanofi. XB: research grants: AbbVie, MSD, Novartis; consultancies: AbbVie, Amgen, Celltrion, Chugai, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB; membership on an entity’s Board of Directors or advisory committees: ASAS President, EULAR President Elect. W-HB: honoraria: AbbVie, Almirall, BMS, Janssen, Leo, Eli Lilly, Novartis, UCB; expert testimony: Novartis; participation on a Data Safety Monitoring Board or Advisory Board: AbbVie, Almirall, BMS, Janssen, Leo, Eli Lilly, Novartis, UCB. IBM: honoraria/consultation fees non-exec roles: NHS GGC Board Member, Evelo Board of Directors, Versus Arthritis Trustee Status; stock or stock options: Evelo, Cabaletta, Compugen, Causeway Therapeutics, Dextera. DGM: research grants: Janssen, AbbVie, Lilly, Novartis, UCB, BMS, Moonlake; consulting fees: Janssen, AbbVie, Lilly, Novartis, UCB, BMS, Moonlake, Celgene; honoraria: Janssen, AbbVie, Lilly, Novartis, UCB, BMS, Moonlake. KLW: research grants: BMS, Pfizer; consulting: Pfizer, AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, GlaxoSmithKline (GSK), Gilead, Novartis, Moderna, Regeneron, Roche, Sanofi, UCB Pharma. AB: speakers fees: AbbVie, Amgen, AlphaSigma, AstraZeneca, Angelini, Biogen, BMS, Berlin-Chemie, Boehringer Ingelheim, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, Teva, UCB, Zentiva; consultancies: Akros, AbbVie, Amgen, AlphaSigma, Biogen, Boehringer Ingelheim, Lilly, Mylan, MSD, Novartis, Pfizer, Roche, Sandoz, Sobi, UCB. PVB: consulting fees: AbbVie, Janssen-Cilag, Pfizer; honoraria: AbbVie, Bausch Health, Celltrion Healthcare, Eli Lilly, Gedeon Richter, IBSA Pharma, Infomed, Janssen-Cilag, Novartis, Pfizer, Sandoz; payment for expert testimony: Gedeon Richter; other: President, Hungarian Association of Rheumatologists. GRB: honoraria and/or speaker fees: AbbVie, BMS, Janssen, Lilly, Novartis, Pfizer. JDC: honoraria: UCB. PC: research grants: AbbVie, Amgen, Biogen, Jansen, Lilly, Novartis, UCB; consulting fees: AbbVie, Amgen, Celltrion, Janssen, Lilly, MSD, Novartis, Pfizer, UCB. LE: consultation fee/advisory board: AbbVie, Novartis, Janssen, UCB, BMS, Eli Lilly; research/educational grants: AbbVie, Fresenius Kabi, Janssen, Amgen, UCB, Novartis, Eli Lilly, Sandoz, Pfizer. MLH: grant support: AbbVie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics BV, Lundbeck Foundation, MSD, Pfizer, Roche, Samsung Bioepis, Sandoz, Novartis, Nordforsk; honoraria: Pfizer, Medac, Sandoz; advisory board: AbbVie; past-chair of the steering committee of the Danish Rheumatology Quality Registry (DANBIO, DRQ), which receives public funding from the hospital owners and funding from pharmaceutical companies; cochair of EuroSpA, partly funded by Novartis. AI: research grants from AbbVie, Pfizer, Novartis; honoraria for lectures, presentations, speakers bureaus from AbbVie, Alfasigma, BMS, Celgene, Celltrion, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi Genzyme, Sobi; EULAR Board Member; EULAR Congress Committee, Education Committee and Advocacy Committee Advisor; EULAR Past President. LEK: consultancies: AbbVie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Pfizer, UCB, Sanofi, GSK, Galapagos, Forward Pharma, MSD, Novartis, Janssen; has been representing rheumatology FOREUM scientific chair. RQ: consultancy and/or speaker’s honoraria from and/or participated in clinical trials and/or research projects sponsored by AbbVie, Amgen-Celgene, Eli Lilly, Novartis, Janssen, Pfizer, MSD, UCB. DM: honoraria: UCB, Janssen, GSK, AstraZeneca, AbbVie; support to meetings: Janssen. HM-O: grant support: Janssen, Novartis, UCB; honoraria and/or speaker fees: AbbVie, Biogen, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, Takeda, UCB. PJM: grant support: AbbVie, Acelyrin, Amgen, Bristol Myers Squibb, Eli Lilly, Genascence, Janssen, Novartis, Pfizer, UCB; consulting fees: AbbVie, Acelyrin, Aclaris, Alumis, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Genascence, Inmagene, Janssen, Moonlake, Novartis, Pfizer, Takeda, UCB, Ventyx, Xinthera; honoraria: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, UCB. PN: consulting fees and honoraria: AbbVie, Amgen, BMS, Lilly, Janssen, GSK, Novartis, UCB, Servatus; boards: Amgen, BMS, Janssen, GSK, Novartis, UCB; GRAPPA Steering Committee, Chair ASMPOC, ARA. LS: consulting fees: AbbVie, Almirall, Novartis, Janssen, Lilly, UCB, Pfizer, Bristol Myers Squibb, Boehringer Ingelheim; honoraria: AbbVie, Almirall, Novartis, Janssen, UCB, Pfizer, Takeda, Galderma, Biogen, Celgene, Celltrion, Lilly, Sanofi, Bristol Myers Squibb, Boehringer Ingelheim; support to attending meetings: AbbVie, Janssen, Lilly, Novartis, UCB, Galderma, Bristol Myers Squibb, Boehringer Ingelheim; participation in boards: AbbVie, Almirall, Novartis, Janssen, UCB, Pfizer, Galderma, Biogen, Lilly, Sanofi, Bristol Myers Squibb, Boehringer Ingelheim; GRAPPA Executive Board (elected), British Society for Medical Dermatology (BSMD) Committee. GS: honoraria: Novartis, Janssen. SJWS-W: grant support: Medical Research Council (MR/W027151/1). YT: research grants from Mitsubishi Tanabe, Eisai, Chugai, Taisho; speaking fees and/or honoraria from Eli Lilly, AstraZeneca, AbbVie, Gilead, Chugai, Boehringer Ingelheim, GlaxoSmithKline, Eisai, Taisho, Bristol Myers, Pfizer, Taiho. FEVdB: consultancy honoraria from AbbVie, Amgen, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB. AZ: speakers bureau: AbbVie, Novartis, Janssen, Lilly, UCB, Amgen; paid instructor for AbbVie, Novartis, UCB. DvdH: consulting fees AbbVie, Argenx, Bayer, BMS, Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Takeda, UCB Pharma; Director of Imaging Rheumatology bv; Associate Editor for Annals of the Rheumatic Diseases; Editorial Board Member for Journal of Rheumatology and RMD Open; Advisor Assessment Axial Spondyloarthritis International Society. JSS: research grants from AbbVie, AstraZeneca, Lilly, Galapagos; royalties from Elsevier (textbook); consulting fees from AbbVie, Galapagos/Gilead, Novartis-Sandoz, BMS, Samsung, Sanofi, Chugai, R-Pharma, Lilly; honoraria from Samsung, Lilly, R-Pharma, Chugai, MSD, Janssen, Novartis-Sandoz; participation in advisory board from AstraZeneca.

Figures

**Figure 1**
2023 EULAR recommendations algorithm for the management of PsA. bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; IBD, inflammatory bowel disease; L, interleukin; JAK, Janus kinase inhibitor; JAKi, Janus kinase inhibitor; NSAID, non-steroidal anti-inflammatory drugs; TNF, tumour necrosis factor; TNFI, tumour necrosis factor inhibitor.

See this image and copyright information in PMC

References

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1. Kerschbaumer A, Smolen JSS, Ferreira JO, et al. . Efficacy and safety of pharmacological treatment of psoriatic arthritis: a systematic literature research informing the 2023 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2024:1–15. doi:ard-2024-225534 - PMC - PubMed

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EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

Affiliations

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

Authors

Affiliations

Abstract

Conflict of interest statement

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MeSH terms

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