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.

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