Screening for cardiovascular disease and other known comorbidities of psoriatic arthritis take new precedence in updated treatment recommendations for rheumatologists from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
“There is some controversy in that addressing comorbidities is thought to be a primary care physician’s responsibility, but I think what’s recognized is that primary care physicians don’t know the literature about psoriatic arthritis in general, so they may not know about the association with these comorbidities,” Dr. Alexis Ogdie-Beatty, one of the recommendations’ authors, said in an interview.
Other common comorbidities cited in the recommendations include obesity, diabetes, and depression, among others (Arthritis Rheumatol. 2016 Jan 8. doi: 10.1002/art.39573).
“These comorbidities exist, and rheumatologists should take them into consideration when making their treatment selection and when discussing things with the patient,” Dr. Ogdie-Beatty said.
GRAPPA’s emphasis on comorbidities sets it apart from other groups that issue treatment guidelines and recommendations, such as the European League Against Rheumatism, she added (Ann Rheum Dis. 2015 Dec 7. doi: 10.1136/annrheumdis-2015-208337).
GRAPPA specifically states that rheumatology specialists should screen patients for a variety of comorbid conditions, including anxiety, depression, and skin cancer, and that they should take an active role in helping overweight and obese patients achieve healthy body weights to reduce their disease activity, particularly patients using tumor necrosis factor inhibitors (TNFis).
If specialists did not want this responsibility, then GRAPPA’s goal was that they “should at least try to educate the primary care physicians about these issues, and educate the patient, too. The primary care doctor could still be responsible for the actual screening,” Dr. Ogdie-Beatty said.
Along with factoring comorbidities in the calculus of treatment, the revised recommendations now are grouped according to disease features, rather than just by the established GRAPPA grid algorithms. Distinctions between mild, moderate, and severe disease as previously described by the grid were removed, the authors wrote, “because the cut-offs are not evidence-based or applicable to all patients.”
Agreement on the development of six new overarching principles of treatment reached at least 80% among the 135 clinicians and 10 patient researchers who evaluated all relevant PsA literature published since 2009 when the last update was published (Ann Rheum Dis. 2009 Sep; 68:1387-94). The most strongly endorsed principle is that the goal of treatment is to “achieve the lowest possible level of disease activity in all domains of disease,” and to “optimize functional status, improve quality of life and well-being, and prevent structural damage to the greatest extent possible.”
The remaining five new guiding principles largely point to the need for an integrated approach to therapy, and an elevated role of the patient in treatment selection. The six clinical domains include peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease in the setting of PsA. Because patients often have multiple manifestations of disease, GRAPPA recommends working with patients in an “iterative process” to choose therapies that address as many of these as possible, beginning with the most severe.
The updated recommendations also address the use of treatments such as IL-17 inhibitors that were unavailable at the time of the last update in 2009, and how they may interplay with the six disease subgroups and comorbidities.
Following are some of the specific recommendations per clinical subgroup. All recommendations are based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method of evidence evaluation.
Peripheral arthritis: With the exception of cyclosporine, in disease-modifying antirheumatic drug (DMARD)–naive patients, DMARDS and TNFis are strongly recommended. Patients with poor prognostic factors, such as high inflammatory markers, are candidates for early escalation of therapy. Patients who fail DMARDs are strongly recommended for either biologics or phosphodiesterase-4 inhibitors, although GRAPPA gives IL-17 inhibitors a conditional recommendation pending more explicit data. NSAIDs are conditionally recommended for symptom relief.
Axial disease: Since relevant data for this subgroup are not available, the recommendations are derived from ankylosing spondylitis and include TNFi for patients who have not responded to NSAIDs. As an adjunct to further therapy when patients fail TNFi, NSAIDs are conditionally recommended. Switching TNFi if there is no response to initial TNFi treatment is also conditionally recommended.
Enthesitis: GRAPPA did not make any recommendations for this subgroup but did note that there is high-quality evidence for TNFi and ustekinumab. The group also did not find any published data to support DMARDs in this group.
Dactylitis: Again, a lack of published data meant GRAPPA had little to recommend for this subgroup, but it did recommend DMARDs based on limited studies for this indication. There was no outright recommendation for corticosteroid injections, although GRAPPA stated they “should be considered.”