This is the lay version of the EULAR recommendations for the management of people with psoriatic arthritis.
The original publication can be downloaded from the EULAR website: www.eular.org.
Gossec L, Smolen JS, Ramiro S, et al European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Annals of the Rheumatic Diseases 2016;75:499-510. doi:10.1136/annrheumdis-2015-208337
Introduction
EULAR recommendations give advice to doctors, nurses and patients about the best way to treat and
manage diseases. EULAR has updated its recommendations on the management of people with psoriatic
arthritis (usually abbreviated as PsA). Psoriatic arthritis is a condition where the joints become stiff, painful and damaged due to the immune system attacking the body’s own tissues and causing inflammation. It is often associated with a skin condition called psoriasis. Psoriasis and psoriatic arthritis are not contagious and you cannot get them from other people.
Doctors, health professionals and patients worked together to develop these recommendations. Including
patients in the team ensured that the patient point of view was integrated in the recommendations. The
authors looked at the evidence on drug interventions in psoriatic arthritis.
What do we already know?
Traditionally, the management of psoriatic arthritis was based on what we knew from rheumatoid arthritis – but there are differences between the two diseases. Today, there are many studies in psoriatic arthritis, and new drugs have become available to treat it, although it cannot be cured. The 2011 EULAR recommendations have therefore been updated to include the new information.
These recommendations include information on several different types of medicines that are used to treat psoriatic arthritis. The medicines can be put into four groups.
- Non-steroidal anti-inflammatory drugs (also called NSAIDs): these drugs only relieve symptoms.
- Disease modifying anti-rheumatic drugs (often shortened to DMARDs) aim to change the course of the disease by reducing inflammation. These drugs can prevent flares and disease worsening. They can also help to improve function and stop the progression of joint damage. Types of DMARDs include:
- Conventional synthetic disease modifying anti-rheumatic drugs (sometimes shortened to csDMARDs).
- Targeted synthetic disease modifying anti-rheumatic drugs (shortened to tsDMARDs)
- Biologic disease modifying anti-rheumatic drugs (also called bDMARDs, biologics or biologicals).
Within each of these groups the medicines may work in different ways to treat the signs and symptoms of the disease. For example, a bDMARD usually works by blocking one specific molecule. By doing this, it reduces inflammation.
What do the recommendations say?
Overall, there are five general principles and ten recommendations. The principles state that psoriatic
arthritis is a variable and potentially severe disease, which may need treatment from different specialists. The treatment of people with psoriatic arthritis should aim for best care, and should be based on a decision made between you and your doctor. Generally, it should be a rheumatologist who manages your care. They should work with other specialists if you have other symptoms, for example, a dermatologist for skin symptoms. The main goal of treating your psoriatic arthritis is to make sure you enjoy the best possible quality of life, with minimal symptoms but also to prevent long-term joint damage and disability. Associated diseases (often called comorbidities) such as those affecting the heart must be considered when choosing treatment.
As well as the general principles, there are ten recommendations. Each recommendation is based on
available scientific evidence or expert opinion. The more stars a recommendation has the stronger the
evidence is and the more important it is that you and your doctor follow it.
One star (*) means it is has limited evidence.
Two stars (**) means it has some evidence.
Three stars (***) means it has quite a lot of evidence.
Four stars (****) means it is supported by a lot of evidence.
-
- Treatment should aim for remission or low disease activity; regular monitoring and adjustment of therapy will help achieve this goal.****
The goal of your treatment should be remission or low disease activity. Remission means that
the disease is well-controlled, there is no longer any inflammation such as swollen joints and
no signs of inflammation in blood tests. However, there may still be some symptoms even in
remission. Low disease activity means that your levels of inflammation are minimal. Your doctor
can help you to achieve these goals by keeping a close eye on your disease by examining you and
asking for tests as needed. Your doctor may also adjust your treatment up or down as needed. - Non-steroidal anti-inflammatory drugs may be used.****
NSAIDs can be used to relieve signs and symptoms in your joints and muscles. They can help to
reduce pain and improve mobility (movement) in your joints, but do not inhibit progression of joint
damage. These drugs will not preserve long-term functioning and will not help the skin. - csDMARDs should be used at an early stage in people with arthritis in the joints of their arms, hands, legs or feet or other symptoms.***
Some people may have arthritis either in the large joints such as elbows, knees and wrists or in the
small joints of their hands and feet (this is called peripheral arthritis). In these people, csDMARDs
should be considered at an early stage, especially if they have many swollen joints, or symptoms in
other parts of their body, such as their eyes. Methotrexate is the preferred drug, especially if you also have skin lesions as part of your disease. - Steroid injections should be considered, and systemic steroids may be used with caution at the lowest effective dose.**
Local injections of glucocorticoids (steroids), for example in joints or near tendons, can be used in
people with psoriatic arthritis to provide relief. Steroids taken by other means (e.g. as tablets) are not usually recommended but may be used with caution at the lowest possible dose. - bDMARDs should be used in people with peripheral arthritis who have not responded to at least one csDMARD.***
If you have peripheral arthritis and have not have good effects from treatment with at least one
csDMARD for several months, you may benefit from therapy with a bDMARD. This will usually be a TNF inhibitor since these are the bDMARDs we have the most experience with. These work by blocking a molecule called TNF (which stands for tumour necrosis factor). TNF is involved in inflammation. - If TNF inhibitors are not appropriate, bDMARDs targeting different cells or molecules may be considered for peripheral arthritis.***
If you have peripheral arthritis and are unable to take TNF inhibitors for some reason, a bDMARD that targets a different cell or molecule may be considered. Some drugs have recently come on the market and seem to work as well as TNF inhibitors. - tsDMARDs may be used for peripheral arthritis if bDMARDs are not appropriate.***
If you have peripheral arthritis and are unable to take bDMARDs for any reason, a tsDMARD may be considered. These types of medicine work in a different way to bDMARDs and are given as pills rather than injections or infusions. - bDMARDs should be considered for people with inflamed tendons, ligaments, and sausage-like fingers or toes.***
If you have inflamed tendons or ligaments or inflamed fingers or toes (sometimes called sausage-like), and have not had good effects from NSAIDs or steroids injections, a bDMARD should be considered even if you have not been given a csDMARD. - bDMARDs should be considered for people with axial disease.***
If your disease is mostly in your back (axial disease) and has not got better with NSAIDs, a TNF inhibitor should be considered without first prescribing a csDMARD. - People who do not respond to bDMARDs should switch treatment.***
If your disease does not improve with a bDMARD, you should be switched to another kind. This might mean switching to another brand of TNF inhibitor, or to a different type of bDMARD that works on a different pathway, or in some cases to a tsDMARD.
- Treatment should aim for remission or low disease activity; regular monitoring and adjustment of therapy will help achieve this goal.****
Summary
Overall, the recommendations highlight that there are many different treatments available for psoriatic
arthritis. Some are more beneficial for specific symptoms than others. If you have psoriatic arthritis these recommendations will give you some guidance on what to expect from your rheumatologist and what
treatments you may be offered.If you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.
Further reading
1. Ramiro S, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015
update of the EULAR recommendations for the management of psoriatic arthritis.
Ann Rheum Dis;75(3):490–8. doi:10.1136/annrheumdis-2015-208466
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