Clinical Topics

New Guidelines Recommend TNFi Biologics as Initial Psoriatic Arthritis Treatment

by Brenda Mooney

August 16, 2019

BIRMINGHAM, AL For the first time, new guidelines have recommended the use of tumor necrosis factor inhibitor biologics as initial therapy for psoriatic arthritis.

While current Group for Research and Assessment of Psoriasis and Psoriatic Arthritis recommendations addressed the use of TNFi biologics in treatment-naïve patients, a conditional recommendation from the American College of Rheumatology and National Psoriasis Foundation specifically advised trying those agents first, over oral small molecule drugs.

The two organizations released a joint treatment guideline for psoriatic arthritis that provides evidence-based pharmacologic and nonpharmacologic recommendations on caring for treatment-naïve patients with active PsA and patients who continue to have active PsA despite treatment. A VA rheumatologist served as principal investigator in developing the guidelines.1

“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first,” explained Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and member of the NPF Medical Board who served as a content expert on the guideline’s core team.” This doesn’t hold true once other symptoms and comorbidities are present, so OSMs can continue to be a first-line option for patients that have contraindications to TNFi treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy. Providers should take into consideration all active disease domains, comorbidities, and the patient’s functional status when choosing the optimal therapy for an individual at a given point in time.”

Tofacitinib was not included within the OSM category, since its benefit/risk profile differs from that of the rest of the class, according to the document.

Another key conditional recommendation was to use a treat-to-target approach for all patients with active PsA. Lead author Jasvinder Singh, MD, MPH, a rheumatologist at the Birmingham VAMC and the University of Alabama at Birmingham, explained why that was important.

“Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” Singh noted. “The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation.”

The guidelines also included recommendations for vaccinations, psoriatic spondylitis, predominant enthesitis and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections.

The strongest recommendation was for smoking avoidance/cessation, based on evidence linking smoking to a reduced efficacy of biologics. The guidelines also emphasized the benefits of smoking cessation; and the documented link between smoking with mortality, cancers and heart and lung diseases even in patients without psoriasis.

That has special significance for veterans and clinicians who treat them. The national Centers for Disease Control and Prevention reported last year that about three in 10 U.S. military veterans used some form of tobacco product during 2010–2015. The article in  Morbidity and Mortality Weekly Report said tobacco product use was higher among veterans than among non-veterans for males and females across all age groups, except males ages 50 years and older.2

CDC used data from the National Survey on Drug Use and Health to assess the different tobacco products currently used (in the past 30 days) by U.S. veterans and nonveterans. Current use among veterans was highest for cigarettes (21.6%), followed by cigars (6.2%), smokeless tobacco (5.2%), roll-your-own tobacco (3.0%), and pipes (1.5%).

Background information in the document pointed out that PsA is a chronic inflammatory musculoskeletal disease most commonly found in patients with psoriasis. NPF estimated that more than eight million Americans have psoriasis and as many as 30% of them might develop PsA.

The PsA guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation methodology, which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. 

Because the quality of evidence sometime was graded low or very low, nearly all recommendations were deemed “conditional.” Consensus was reached on the direction and strength of recommendations by a voting panel of rheumatologists, dermatologists, health professionals and patients.

“Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions,” Singh noted. “This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations.”

The VA might face challenges in adjusting to the new guidelines. A recent study found that use of rheumatology care and disease-modifying antirheumatic drugs remained fairly low in VA patients, including those with psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis.

The study, published in the Journal of Rheumatology sought to evaluate the effect of access to and distance from rheumatology care on the use of DMARDs, whether synthetic or biologic.3

The Salt Lake City VAMC-led investigation evaluated provider encounters and DMARD dispensations for inflammatory arthritis, using national VA datasets between Jan. 1, 2015, and Dec. 31, 2015.

Results indicated that, among 12,589 veterans with IA, 23.5% saw a rheumatology provider. In the general IA population, 25.3% and 13.6% of veterans were treated with synthetic DMARD and biologic DMARD , respectively. 

Researchers pointed out that DMARD exposure was 2.6- to 3.4-fold higher in the subpopulation using rheumatology providers, compared to the general IA population. 

One factor was geography. The study teamed defined the distance between veterans’ homes and the closest VA rheumatology site as “near” if it was less than 40 miles, which was the case for 55.9% of the patients, “intermediate” if it was 40-99 miles, 31.7%, and “far” if the distance was 100 miles or greater, which was the case with 12.4% of the participants.

The study determined that veterans in the Intermediate and Far groups were less likely to see a rheumatology provider than veterans in the Near group (RR = 0.72 and RR = 0.49, respectively). In fact, exposure to bDMARD was 34% less frequent in the Far group than the Near group.

In the subpopulation who used rheumatology care, however, the bDMARD exposure discrepancy did not persist between distance groups, the researchers noted.

“Use of rheumatology care and DMARD was low for veterans with IA. DMARD exposure was strongly associated with rheumatology care use,” the study authors concluded. “Veterans in the general IA population living far from rheumatology sites accessed rheumatology care and bDMARD less frequently than veterans living close to rheumatology sites.”

Even though a psoriasis diagnosis is a barrier to enlistment in the U.S. military, cases persist. A recent article in Military Medicine noted, “Under current U.S. Army regulation, the diagnosis of psoriasis is a bar to enlistment or appointment and, if poorly controlled, is grounds for referral to a Medical Evaluation Board and potential discharge from military service, according to Army Regulation 40-501. However, between 2008 and 2015, over 3,600 soldiers sought care for psoriasis while deployed to combat theaters, indicating that psoriasis remains a significant medical concern in the U.S. military.”4

1. Singh JA, Guyatt G, Ogdie A, Gladman DD, et. Al. Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care Res (Hoboken).2019 Jan;71(1):2-29. doi: 10.1002/acr.23789. Epub 2018 Nov 30. PubMed PMID: 30499259.

2. Odani S, Agaku IT, Graffunder CM, Tynan MA, Armour BS. Tobacco Product Use Among Military Veterans — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2018;67:7–12. DOI:

3. Walsh JA, Pei S, Burningham Z, Penmetsa G, Cannon GW, Clegg DO, Sauer BC. Use of Disease-modifying Antirheumatic Drugs for Inflammatory Arthritis in US Veterans: Effect of Specialty Care and Geographic Distance. J Rheumatol. 2018 Mar;45(3):430-436. doi: 0.3899/jrheum.170554. Epub 2017 Nov 15. PubMed PMID:29142040.

4. Rosenberg A, Meyerle J. The Use of Apremilast to Treat Psoriasis During Deployment. Mil Med. 2017 Jul;182(7):1628-1631. doi: 10.7205/MILMED-D-17-00047. PubMed PMID: 28810954.

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