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Psoriatic Arthritis Eular

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Psoriatic Arthritis Eular

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Recommendation

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Dennis McGonagle,12,13 Kevin L Winthrop ‍ ‍,14 Andra Balanescu,15 Peter V Balint,16
Gerd R Burmester ‍ ‍,17 Juan D Cañete ‍ ‍,18,19 Pascal Claudepierre,20,21
Lihi Eder ‍ ‍,22 Merete Lund Hetland ‍ ‍,23,24 Annamaria Iagnocco ‍ ‍,25
Lars Erik Kristensen,26,27 Rik Lories,28,29 Rubén Queiro ‍ ‍,30,31 Daniele Mauro ‍ ‍,32
Helena Marzo-Ortega ‍ ‍,12,13 Philip J Mease ‍ ‍,33,34 Peter Nash ‍ ‍,35
Wendy Wagenaar,36,37 Laura Savage,38 Georg Schett ‍ ‍,39
Stephanie J W Shoop-Worrall ‍ ‍,40 Yoshiya Tanaka ‍ ‍,41 Filip E Van den Bosch ‍ ‍,42
Annette van der Helm-van Mil,43 Alen Zabotti ‍ ‍,44 Désirée van der Heijde ‍ ‍,43
Josef S Smolen3

Handling editor Dimitrios T ABSTRACT INTRODUCTION

Boumpas Objective New modes of action and more data on Psoriatic arthritis (PsA) is a disease which has
For numbered affiliations see the efficacy and safety of existing drugs in psoriatic benefited from notable progress over recent years.
end of article. arthritis (PsA) required an update of the EULAR 2019 Concepts have evolved, such as very early diag-
recommendations for the pharmacological treatment of nosis and pre- PsA, as well as defining treatment
Correspondence to PsA. targets and applying a holistic approach to comor-
Laure Gossec; Methods Following EULAR standardised operating bidity management.1–4 Pharmacological options
laure.gossec@a php.fr have extended, with the approval of new agents
procedures, the process included a systematic literature
Received 15 January 2024 review and a consensus meeting of 36 international targeting various modes of action for PsA (as well as
Accepted 26 February 2024 experts in April 2023. Levels of evidence and grades of skin psoriasis). Drugs licensed for PsA now include
Published Online First recommendations were determined. (1) conventional synthetic (cs) disease- modifying
18 March 2024 antirheumatic drugs (DMARDs), such as metho-
Results The updated recommendations comprise 7
overarching principles and 11 recommendations, and trexate (MTX), sulfasalazine and leflunomide; (2)
provide a treatment strategy for pharmacological therapies. biological (b) DMARDs targeting tumour necrosis
Non-steroidal anti-inflammatory drugs should be used in factor (TNF), the interleukin (IL)-12/23 or IL-23
monotherapy only for mild PsA and in the short term; oral pathway, and the IL-17A and IL-17A/F pathway;
glucocorticoids are not recommended. In patients with and (3) targeted synthetic (ts) DMARDs that
peripheral arthritis, rapid initiation of conventional synthetic inhibit Janus kinases (JAKs) or phosphodiesterase
disease-modifying antirheumatic drugs is recommended 4 (PDE4) (table 1).5 New safety data have emerged
and methotrexate preferred. If the treatment target is not in inflammatory arthritis, particularly a worldwide
achieved with this strategy, a biological disease-modifying cautionary comment regarding JAK inhibitors
antirheumatic drug (bDMARD) should be initiated, without (JAKis), following a large randomised controlled
preference among modes of action. Relevant skin psoriasis trial (RCT) of tofacitinib in rheumatoid arthritis
should orient towards bDMARDs targeting interleukin (IL)- (RA).6–8 Since the last EULAR recommendations for
23p40, IL-23p19, IL-17A and IL-17A/F inhibitors. In case of the pharmacological management of PsA in 2019,
predominant axial or entheseal disease, an algorithm is also the field has changed significantly.9–12 An update
proposed. Use of Janus kinase inhibitors is proposed primarily of the EULAR PsA management recommendations
was therefore timely.9
© European Alliance of after bDMARD failure, taking relevant risk factors into
Associations for Rheumatology, This update addresses the non-topical, pharma-
account, or in case bDMARDs are not an appropriate choice.
EULAR 2024. Re-use permitted cological management of PsA, with a specific focus
Inflammatory bowel disease and uveitis, if present, should
under CC BY-NC-ND. No on musculoskeletal (MSK) manifestations, while
commercial re-use. No influence drug choices, with monoclonal tumour necrosis
also addressing the spectrum of PsA, including
derivatives. See rights and factor inhibitors proposed. Drug switches and tapering in
permissions. Published by BMJ how skin psoriasis, extra-MSK manifestations and
sustained remission are also addressed.
on behalf of EULAR. comorbidities should influence treatment choices.
Conclusion These updated recommendations integrate
To cite: Gossec L, all currently available drugs in a practical and progressive
Kerschbaumer A, Ferreira RJO, approach, which will be helpful in the pharmacological METHODS
et al. Ann Rheum Dis management of PsA. In accordance with the EULAR updated stan-
2024;83:706–719. dardised operating procedures,13 the process
706 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531
Recommendation

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► Golimumab
IL-12/23 ► Ustekinumab based and consensus- based, and included consideration of
IL-17A ► Ixekizumab
safety, efficacy, cost and long-term data. The levels of evidence
► Secukinumab (LoE) and grades of recommendation (GoR) were determined
IL-17A/F ► Bimekizumab for each recommendation based on the Oxford Evidence Based
IL-23-p19 ► Guselkumab System.13 14 In May 2023, an anonymised email-based voting on
► Risankizumab the level of agreement (LoA) among the taskforce members was
CTLA4 ► Abatacept performed on a 0–10 scale (with 10 meaning full agreement)
tsDMARD PDE4 ► Apremilast allowing calculation of mean LoA.
JAK ► Tofacitinib.
► Upadacitinib. RESULTS
Drugs currently authorised as of December 2023 for use in psoriatic arthritis. These recommendations address non- topical pharmacological
bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional treatments with a main focus on MSK manifestations. These
synthetic disease-modifying antirheumatic drug; DMARD, disease-modifying
recommendations concern stakeholders, such as experts involved
antirheumatic drug; IL, interleukin; JAK, Janus kinase; PDE4, phosphodiesterase
4; TNF, tumour necrosis factor; tsDMARD, targeted synthetic disease-modifying in the care of patients with PsA, particularly rheumatologists
antirheumatic drug. and other health professionals (such as rheumatology nurses),
general practitioners, dermatologists and other specialists; and
also people with PsA as well as other stakeholders, for example,
government and hospital officials, patient organisations, regula-
leading to this update included a data- driven approach and
tory agencies and reimbursement institutions.
expert opinion.
The overarching principles (OAPs) and recommendations
After approval for an update by the EULAR Council in
are shown in table 2, with LoE, GoR and LoA. The updated
September 2022, taskforce members were selected by the
recommendations include 7 OAPs (vs 6 in 2019) and 11 recom-
convenor (JSS) and the methodologist (LG), to include more
mendations (vs 12 in 2019, due to merges). Of the 11 recom-
than one-third of new members, as well as country and gender
mendations, only 4 are unchanged compared with 2019 (the
representation. For the first time, experts from Australia, Japan
modifications compared with the 2019 recommendations are
and North America participated. Representatives from the
represented in table 3).
health professionals in rheumatology (HPR) committee, patient
research partners from PARE (People with Arthritis/Rheuma-
tism) and young colleagues from the EMEUNET (EMerging Overarching principles
EUlar NETwork) were included. Five members were recruited Of the seven OAPs, three remain unchanged, three were
through an open call to EULAR countries via a competitive reworded and one has been added (overarching principle G). For
application process. more information on the thought process leading to the OAPs
In October 2022, the steering group had its first meeting. The (unchanged or slightly changed), please refer to the 2015 and
steering group consisted of seven rheumatologists (including the 2019 recommendations manuscripts.9 15 Key points from the
convenor, the methodologist and the fellow: JSS, LG, AK, DA, discussion of the OAPs are addressed in the following:
XB, IBM and DGM), a dermatologist (W-HB), an infectious A. Psoriatic arthritis is a heterogeneous and potentially
disease specialist (KLW), an experienced fellow rheumatologist severe disease, which may require multidisciplinary treatment
(AK), a patient research partner (HB) and two health profes- (unchanged).
sionals (BAE and RJOF, the latter acting in the capacity of a junior Although PsA is potentially severe, not all patients will develop
methodologist). Questions were then defined and addressed severe forms.16 17 Multidisciplinary management is helpful
through a systematic literature review (SLR), performed by the for many patients, through collaboration between physicians
fellow (AK) between November 2022 and April 2023, for the of different specialties and HPRs with the appropriate exper-
literature pertaining to pharmacological treatments of PsA and tise.18 19
published since the previous SLR (ie, since the end of 2018).5 B. Treatment of psoriatic arthritis patients should aim at the
The taskforce comprised the steering group and 23 other best care and must be based on a shared decision between the
experts; members came from 19 different countries (of which patient and the rheumatologist, considering efficacy, safety,
15 were EULAR countries), and included 27 rheumatology patient preferences and costs.
specialists, 2 dermatologists, 1 infectious disease specialist, 2 This OAP was modified from 2019 to add patient preferences
people affected with PsA acting as patient research partners, as an element to be considered and emphasise the importance of
2 HPRs and 3 rheumatology/epidemiology fellows/trainees. shared decision-making to maximise treatment adherence and
Overall, 47% of the taskforce members had not participated in efficacy while at the same time minimise complications driven
the previous update in 2019. In April 2023, the taskforce met by uncontrolled (active) disease as well as potential side effects
for a physical meeting to develop the updated bullet points. Each of pharmacological drugs.20 21
Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 707
Recommendation

A Psoriatic arthritis is a heterogeneous and potentially severe disease, which may require multidisciplinary treatment. 10.0 (0.1)
B Treatment of psoriatic arthritis patients should aim at the best care and must be based on a shared decision between the patient and 9.7 (0.6)
the rheumatologist, considering efficacy, safety, patient preferences and costs.
C Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with psoriatic 9.7 (0.5)
arthritis; in the presence of clinically relevant skin involvement, a rheumatologist and a dermatologist should collaborate in diagnosis
and management.
D The primary goal of treating patients with psoriatic arthritis is to maximise health-related quality of life, through control of symptoms, 9.9 (0.3)
prevention of structural damage, normalisation of function and social participation; abrogation of inflammation is an important
component to achieve these goals.

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E In managing patients with psoriatic arthritis, consideration should be given to each musculoskeletal manifestation and treatment 9.8 (0.4)
decisions made accordingly.
F When managing patients with psoriatic arthritis, non-musculoskeletal manifestations (particularly skin, eye and gastrointestinal tract) 9.7 (0.7)
should be taken into account; comorbidities such as obesity, metabolic syndrome, cardiovascular disease or depression should also be
considered.
G The choice of treatment should take account of safety considerations regarding individual modes of action to optimise the benefit– 9.9 (0.4)
risk profile.
Recommendations Level of evidence Grade of Level of agreement, mean (SD)
recommendation
1 Treatment should be aimed at reaching the target of remission or, 1b A 9.5 (1.0)
alternatively, low disease activity, by regular disease activity assessment
and appropriate adjustment of therapy.
2 Non-steroidal anti-inflammatory drugs may be used to relieve 1ba, 3bb Aa, Cb 9.5 (0.7)
musculoskeletal signs and symptomsa; local injections of glucocorticoids
may be considered as adjunctive therapyb.
3 In patients with polyarthritis, or those with monoarthritis/oligoarthritis 1b, 4a B, Ca 9.3 (0.8)
and poor prognostic factorsa (eg, structural damage, elevated acute
phase reactants, dactylitis or nail involvement), a csDMARD should be
initiated rapidly, with methotrexate preferred in those with clinically
relevant skin involvement.
4 In patients with peripheral arthritis and an inadequate response to at 1a A 9.5 (1.3)
least one csDMARD, therapy with a bDMARD should be commenced.
5 In patients with peripheral arthritis and an inadequate response to at 1b, 4a B, Da 9.1 (1.5)
least one bDMARD, or when a bDMARD is not appropriatea, a JAKi may
be considered, taking safety considerations* into account.
6 In patients with mild disease and an inadequate response to at least 1b B 8.7 (1.1)
one csDMARD, in whom neither a bDMARD nor a JAKi* is appropriate, a
PDE4 inhibitor may be considered.
7 In patients with unequivocal enthesitis and an insufficient response to 1b B 9.5 (0.9)
NSAIDs or local glucocorticoid injections, therapy with a bDMARD should
be considered.
8 In patients with clinically relevant axial disease with an insufficient 1b B 9.4 (1.3)
response to NSAIDs, therapy with an IL-17A inhibitor, a TNF inhibitor, an
IL-17 A/F inhibitor or a JAKi* should be considered.
9 The choice of the mode of action should reflect non-musculoskeletal 1b B 9.6 (0.7)
manifestations related to psoriatic arthritis; with clinically relevant skin
involvement, preference should be given to an IL-17A or IL-17A/F or IL-
23 or IL-12/23 inhibitor; with uveitis to an anti-TNF monoclonal antibody;
and with IBD to an anti-TNF monoclonal antibody or an IL-23 inhibitor or
IL-12/23 inhibitor or a JAKi*.
10 In patients with an inadequate response or intolerance to a bDMARD or 1ba, 4b C 9.5 (0.7)
a JAKi, switching to another bDMARD or JAKi* should be considereda,
including one switch within a classb.
11 In patients in sustained remission, tapering of DMARDs may be 2b B 9.4 (1.2)
considered.
‘Mild disease’ is defined as oligoarticular or entheseal disease without poor prognostic factors and limited skin involvement.
csDMARDs (conventional synthetic DMARDs) include methotrexate, sulfasalazine or leflunomide. bDMARDs (biologic DMARDs) here include TNF inhibitors (both original and biosimilars), drugs targeting the IL-17 and
IL-12–23/IL-23-p19 pathways, and in the context of recommendation 10 also CTLA4 (cytotoxic T-lymphocyte–associated antigen 4) inhibition. JAKis (Januse kinase inhibitors) include tofacitinib and upadacitinib.
The superscript letters ‘a’ and ‘b’ are used to link a part of the recommendation to a level of evidence.
The table shows the level of evidence, grade of recommendation and level of agreement among taskforce members (0–10 scale).
*For JAKis, caution is needed for patients aged 65 years or above, those who are current or past long-time smokers, with a history of atherosclerotic cardiovascular disease or other cardiovascular risk factors or with
other malignancy risk factors, and with known risk factors for venous thromboembolism.
bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; CTLA4, cytotoxic T-lymphocyte–associated antigen 4; DMARDs, disease-modifying
antirheumatic drugs; IBD, inflammatory bowel disease; IL, interleukin; JAKi, Janus kinase inhibitor; NSAIDs, non-steroidal anti-inflammatory drugs; PDE4, phosphodiesterase 4; TNF, tumour necrosis factor.

C. Rheumatologists are the specialists who should primarily aspects of safety and comorbidities. Consultation with
care for the musculoskeletal manifestations of patients with psori- dermatologists and sometimes other specialists may be
atic arthritis; in the presence of clinically relevant skin involve- helpful in individual clinical scenarios (see also overarching
ment, a rheumatologist and a dermatologist should collaborate in principles F and G). A very slight rewording was performed
diagnosis and management. to discuss skin involvement as ‘clinically relevant’ rather
We consider that rheumatology experts provide the best than ‘clinically significant’ for more homogeneity with
care for patients with PsA, given their experience with the other bullet points. This bullet point does not address the
many drugs used to treat these and other rheumatic and role of HPRs, who are usually not prescribers in EULAR
musculoskeletal diseases (RMDs), including the important countries.
708 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531
Recommendation

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primarily care for the musculoskeletal manifestations for the musculoskeletal manifestations of patients with psoriatic
of patients with psoriatic arthritis; in the presence arthritis; in the presence of clinically relevant skin involvement,
of clinically significant skin involvement, a a rheumatologist and a dermatologist should collaborate in
rheumatologist and a dermatologist should diagnosis and management.
collaborate in diagnosis and management.
D The primary goal of treating patients with psoriatic Unchanged D The primary goal of treating patients with psoriatic arthritis is
arthritis is to maximise health-related quality of to maximise health-related quality of life, through control of
life, through control of symptoms, prevention of symptoms, prevention of structural damage, normalisation of
structural damage, normalisation of function and function and social participation; abrogation of inflammation is
social participation; abrogation of inflammation is an an important component to achieve these goals.
important component to achieve these goals.
E In managing patients with psoriatic arthritis, Unchanged E In managing patients with psoriatic arthritis, consideration should
consideration should be given to each musculoskeletal be given to each musculoskeletal manifestation and treatment
manifestation and treatment decisions made decisions made accordingly.
accordingly.
F When managing patients with psoriatic arthritis, Reformulated F When managing patients with psoriatic arthritis, non-
non-musculoskeletal manifestations (skin, eye musculoskeletal manifestations (particularly skin, eye and
and gastrointestinal tract) should be taken into gastrointestinal tract) should be taken into account; comorbidities
account; comorbidities such as metabolic syndrome, such as obesity, metabolic syndrome, cardiovascular disease or
cardiovascular disease or depression should also be depression should also be considered.
considered.
New G The choice of treatment should take account of safety
considerations regarding individual modes of action to optimise
the benefit–risk profile.
Recommendations
1 Treatment should be aimed at reaching the target of Unchanged 1 Treatment should be aimed at reaching the target of remission or,
remission or, alternatively, low disease activity, by alternatively, minimal/low disease activity, by regular monitoring
regular disease activity assessment and appropriate and appropriate adjustment of therapy.
adjustment of therapy.
2 and 3 Non-steroidal anti-inflammatory drugs may Merged and modified 2 Non-steroidal anti-inflammatory drugs may be used to relieve
be used to relieve musculoskeletal signs and musculoskeletal signs and symptoms; local injections of
symptoms. glucocorticoids may be considered as adjunctive therapy.
Local injections of glucocorticoids should be
considered as adjunctive therapy in psoriatic
arthritis; systemic glucocorticoids may be used
with caution at the lowest effective dose.
4 and 5 In patients with polyarthritis, a csDMARD should Merged and modified 3 In patients with polyarthritis, or those with monoarthritis/
be initiated rapidly, with methotrexate preferred oligoarthritis and poor prognostic factors (eg, structural damage,
in those with relevant skin involvement. elevated acute phase reactants, dactylitis or nail involvement),
In patients with monoarthritis or oligoarthritis, a csDMARD should be initiated rapidly, with methotrexate
particularly with poor prognostic factors preferred in those with clinically relevant skin involvement.
such as structural damage, high erythrocyte
sedimentation rate / C-reactive protein, dactylitis
or nail involvement, a csDMARD should be
considered.
6 In patients with peripheral arthritis and an inadequate Split into two recommendations 4 In patients with peripheral arthritis and an inadequate response
response to at least one csDMARD, therapy with to at least one csDMARD, therapy with a bDMARD should be
a bDMARD should be commenced; when there is commenced.
relevant skin involvement, an IL-17 inhibitor or IL-
12/23 inhibitor may be preferred.
7 In patients with peripheral arthritis and an inadequate Modified 5 In patients with peripheral arthritis and an inadequate response
response to at least one csDMARD and at least one to at least one bDMARD, or when a bDMARD is not appropriate,
bDMARD, or when a bDMARD is not appropriate, a a JAKi may be considered, taking safety considerations into
JAK inhibitor may be considered. account.
8 In patients with mild disease and an inadequate Unchanged 6 In patients with mild disease and an inadequate response to at
response to at least one csDMARD, in whom neither least one csDMARD, in whom neither a bDMARD nor a JAKi is
a bDMARD nor a JAK inhibitor is appropriate, a PDE4 appropriate, a PDE4 inhibitor may be considered.
inhibitor may be considered.
9 In patients with unequivocal enthesitis and Unchanged 7 In patients with unequivocal enthesitis and an insufficient
insufficient response to NSAIDs or local glucocorticoid response to NSAIDs or local glucocorticoid injections, therapy
injections, therapy with a bDMARD should be with a bDMARD should be considered.
considered.
10 In patients with predominantly axial disease which Modified 8 In patients with clinically relevant axial disease with an
is active and has insufficient response to NSAIDs, insufficient response to NSAIDs, therapy with an IL-17Ai, a TNFi,
therapy with a bDMARD should be considered, which an IL-17 A/Fi or a JAKi should be considered.
according to current practice is a TNF inhibitor; when
there is relevant skin involvement, IL-17 inhibitor may
be preferred.

Continued

Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 709

Recommendation

New 9 The choice of the mode of action should reflect non-

musculoskeletal manifestations related to psoriatic arthritis; with
clinically relevant skin involvement, preference should be given to
an IL-17A or IL-17A/F or IL-23 or IL-12/23 inhibitor; with uveitis
to an anti-TNF monoclonal antibody; and with IBD to an anti-TNF
monoclonal antibody or an IL-23i or IL-12/23i or a JAKi.
11 In patients who fail to respond adequately to or Modified 10 In patients with an inadequate response or intolerance to a
are intolerant of a bDMARD, switching to another bDMARD or a JAKi, switching to another bDMARD or JAKi should
bDMARD or tsDMARD should be considered, including be considered, including one switch within a class.
one switch within a class.

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12 In patients in sustained remission, cautious tapering Reformulated 11 In patients in sustained remission, tapering of DMARDs may be
of DMARDs may be considered. considered.
bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; DMARD, disease-modifying antirheumatic drug; IBD, inflammatory bowel disease;
IL, interleukin; JAK, Janus kinase; JAKi, Janus kinase inhibitor; NSAID, non-steroidal anti-inflammatory drug; PDE4, phosphodiesterase 4; TNF, tumour necrosis factor; TNFi, tumour necrosis factor inhibitor; tsDMARD,
targeted synthetic disease-modifying antirheumatic drug.

D. The primary goal of treating patients with psoriatic Recommendations

arthritis is to maximise health-related quality of life, through Of note, these recommendations are centred on non- topical
control of symptoms, prevention of structural damage, normal- pharmacological treatments; topical and non-pharmacological
isation of function and social participation; abrogation of treatments are also important in PsA but are outside our scope.
inflammation is an important component to achieve these Figure 1 shows a summarised algorithm of the treatment
goals (unchanged). proposals.
For more details, please see the 2019 update of these Some safety issues will be briefly addressed, but for a full
recommendations.9 picture of the adverse event profile of different drugs the package
E. In managing patients with psoriatic arthritis, consideration inserts should be consulted.
should be given to each musculoskeletal manifestation and treat-
ment decisions made accordingly (unchanged). Recommendation 1
For more details, please refer to the 2019 update.9 Treatment should be aimed at reaching the target of remission
F. When managing patients with psoriatic arthritis, non- or, alternatively, low disease activity, by regular disease activity
musculoskeletal manifestations (skin, eye and gastrointestinal assessment and appropriate adjustment of therapy.
tract) should be taken into account; comorbidities such as obesity, This (unchanged) recommendation is in keeping with the
metabolic syndrome, cardiovascular disease or depression should principles of treating-to-target.26 27 Given the lack of new data
also be considered. to support treat-to-target in PsA, the LoE and GoR are also
The wording ‘such as obesity’ was added, since obesity unchanged. The use of instruments to assess disease activity has
is frequent in PsA and can influence outcomes.22 23 Obesity been addressed in the treat-to-target recommendations.26 The
concerns excess body fat, while metabolic syndrome is a collec- definition of remission in PsA remains a subject of debate.28–30
tion of risk factors that increase the likelihood of developing For the context of these recommendations, remission should be
cardiovascular disease and type 2 diabetes. Obesity is a signif- seen as an abrogation of inflammation.
icant contributor to the development of metabolic syndrome. The taskforce members emphasised that disease activity
The taskforce members discussed if other comorbidities should should be regularly assessed across individual involved mani-
be added, but it was felt that the term ‘such as’ entails that festations (eg, joints, skin, enthesitis, dactylitis, axial disease),
comorbidities overall should be considered, without a need to and that treatment adjustments will depend on the predominant
list them. Depression and potentially other mental health issues manifestation of the disease at a given moment.31
may influence treatment choice. Central sensitisation to pain
perception is frequent in PsA and also influences outcomes; Recommendation 2
this may lead to difficulties in disease management.24 25 Bone Non-steroidal anti-inflammatory drugs may be used to relieve
health and malignancies were also specifically highlighted. The musculoskeletal signs and symptoms; local injections of gluco-
management of comorbidities poses specific issues, in particular corticoids may be considered as adjunctive therapy.
as to who is responsible for managing distinct disease domains. This recommendation deals with the short- term use of
Solutions need to be applied according to the individual symptomatic treatment. It was developed by merging the two
patient, each country’s specific setting and healthcare system previous recommendations 2 and 3, which dealt separately with
organisation. non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorti-
G. The choice of treatment should take account of safety coids, as both only serve to relieve symptoms in the short term.
considerations regarding individual modes of action to optimise It was decided to no longer allude to systemic glucocorticoids
the benefit–risk profile (new). in a bullet point, since the data underlying the prescription of
Given new data on the safety of different modes of action, the systemic glucocorticoids in PsA are scarce. Moreover, glucocor-
taskforce proposed this new OAP to emphasise the importance ticoids harbour many potential safety issues, in particular when
of taking into account safety considerations for each patient.6 taking into account the high prevalence of comorbidities and
The taskforce was aware that this item is somewhat redundant cardiovascular risk factors in PsA.3 32 However, the taskforce
with overarching principle B but wished to emphasise the impor- members agreed that, in some selected cases, systemic glucocor-
tance of benefit–risk assessment when considering the use of ticoid therapy may be helpful for some patients, especially for
specific agents. polyarticular forms and/or as bridging therapy.
710 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531
Recommendation

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.

Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 711

Recommendation

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entheseal or axial disease, may sufficiently benefit from NSAIDs Very early PsA ► Biomarkers for pre-PsA.
► Defining screening strategies for PsA among patients with psoriasis:
as monotherapy. Even in these cases, it is proposed that the use is screening needed, and if so in which populations, how and when?
of symptomatic treatments alone should usually be short term, ► Criteria for early diagnosis of PsA and role of imaging.
► Prevention of progression from psoriasis to PsA: pre-PsA therapy/
for example, limited to 4 weeks or so. In peripheral arthritis, this interception (efficacy of DMARDs in preventing progression from
duration is based on the opinion of the group; in predominant Pso to PsA).
axial disease, it is in keeping with the Assesment of Spondyloar- ► Window of opportunity studies.

thritis International Society (ASAS)/EULAR recommendations Drug ordering/ ► Research on the effect of sex on treatment choices, treatment
response prediction efficacy and treatment maintenance.
for axial spondyloarthritis (axSpA) whereby persistent disease and biomarkers ► Incorporating ultrasonography in decision-making.
after 4 weeks of treatment is considered a failure of NSAIDs.33 ► Biomarkers for prediction of disease and response.
► Prediction of response with genetics and polygenetics.
On the other hand, for patients with predominant axial disease
Prognosis ► Prognostic factors of progressive disease, structural damage and
who experience significant improvement in clinical symptoms, unfavourable functional outcomes.
continuous NSAID use may be proposed if needed to control ► Predicting response to treatment (predicting response to NSAIDs, to
csDMARDs, to the different bDMARDs, to tsDMARDs).
symptoms, always taking the risks and benefits into account. ► Prognosis of early-onset (juvenile) PsA.
Of note, data regarding the efficacy of NSAIDs in enthesitis are First DMARD choices ► Biosimilars vs methotrexate as first choice—strategy trials.
limited. ► Comparing direct and indirect costs, efficacy, side effects in
employed, early, severe, bio-naïve PsA patient groups treated
with methotrexate or biosimilars. Is there any advantage of using
methotrexate over biosimilars in this group?
Recommendation 3 Outcomes in PsA ► Development/validation of composite scores of disease activity in
In patients with polyarthritis or those with monoarthritis/ PsA.
oligoarthritis and poor prognostic factors (eg, structural damage, ► Consensus on core outcomes in PsA trials.
► Coprimary outcomes for skin and joints.
elevated acute phase reactants, dactylitis or nail involvement), ► Efficacy of apremilast on structural changes.
a csDMARD should be initiated rapidly, with methotrexate ► Drug-free remission as an outcome in PsA.
preferred in those with clinically relevant skin involvement. Treatments ► Efficacy of csDMARDs for dactylitis.
► Assessing combinations of csDMARDs with biologics compared with
Among patients with peripheral arthritis,34 35 a distinction is biologics monotherapy.
made according to the number of swollen joints and according ► Associations of bDMARDs.
to prognostic factors.36 In 2019, polyarthritis and monoarthritis/ Contextual factors ► Sex and gender.
oligoarthritis with poor prognostic markers were addressed in in PsA ► Age.
Safety ► Differential JAKi safety in PsA and across drugs.
separate bullet points, which were merged for clarity in this ► Tyrosine-kinase inhibition safety in PsA.
update (table 3). Oligoarticular disease is defined as arthritis ► Long-term safety trials in PsA.
(swollen joints) of up to four (included) joints.9 This definition Axial PsA ► Pathogenesis of axial PsA vs axSpA.
applies to clinical detection (rather than imaging). The prog- ► Criteria for differentiation and overlap between axSpA and PsA.
► JAKis in axial PsA.
nostic factors have also been previously defined9 17 and are ► Assessment of spinal disease: defining the similarities and
unchanged. differences with axSpA.
We recommend rapid csDMARD start, concomitant (or close) Comorbidities ► Impact of comorbidities on drug choice.
► Effect of metabolic intervention on disease activity.
with the initiation of symptomatic therapy, for both patients with ► Effect of different DMARDs on cardiovascular risk.
polyarticular disease and patients with oligoarticular disease and ► Influence of non-pharmacological interventions on multimorbidity.
poor prognostic factors. Patients with oligoarticular disease and ► Entheseal PsA: overlap with widespread pain syndrome and role of
imaging in the diagnosis.
lack of poor prognostic factors should also receive a csDMARD, ► Treatment of pain which does not respond to usual therapies.
but there is less urgency for these patients given the more favour- ► Fatigue in PsA.
► Unravelling complexities of difficult-to-manage PsA.
able long-term prognosis. The latter may receive csDMARDs
Switches ► Repeat switching within a DMARD class.
after a longer delay, and potentially a period of symptomatic ► Switching and cycling between drugs.
treatment alone (see recommendation 2). Since there is a lack axSpA, axial spondyloarthritis; bDMARDs, biological disease-modifying antirheumatic drugs;
of strong evidence to support this approach of rapid treatment csDMARDs, conventional synthetic disease-modifying antirheumatic drugs; DMARDs, disease-modifying
antirheumatic drugs; JAKi, Janus kinase inhibitor; NSAIDs, non-steroidal anti-inflammatory drugs; PsA,
introduction, this recommendation was mainly based on expert psoriatic arthritis; tsDMARDs, targeted synthetic disease-modifying antirheumatic drugs.
opinion.
Of note, there is no specific recommendation for dactylitis.
We consider dactylitis as an association of (oligo)synovitis, teno- first-
line DMARD is important and led to much taskforce
synovitis and enthesitis. Patients with isolated dactylitis should discussion, and has been put as an element for further research
be treated similarly to patients with oligoarthritis; this includes in the research agenda (table 4). The continued prioritisation of
the use of joint glucocorticoid injections and csDMARDs, which csDMARDs reflects consensual expert opinion within the task-
have shown efficacy in relieving dactylitis.37 force that favoured the benefit–risk–cost balance of csDMARDs
The first DMARD should be a csDMARD (meaning MTX, and in particular MTX over targeted drugs. The absence of new
leflunomide or sulfasalazine). The decision concerning the data indicating the superiority of a b/tsDMARD as first-line, and
712 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531
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Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.
the T2T recommendations.26 Although MTX use in PsA has typi- with IL-17A and IL-17A/F inhibition, particularly the latter.53 54
cally been founded on evidence from other immune-mediated While IL-23-p19i is a more recent addition to the armament, its
diseases such as RA and psoriasis,40 there is also evidence for its safety appears satisfactory, in line with ustekinumab which also
efficacy in PsA, with recent confirmatory data both from obser- interferes with IL-23 (p40 chain) whose adverse event profile is
vational data sources and from a randomised trial indicating well known and appears satisfactory.5
that a proportion of patients will respond to escalation of doses As a general rule, safety and comorbidities need to be taken
of MTX.39 41–43 The efficacy–safety balance of MTX should be into account when a decision to start a new drug is taken. More
assessed regularly, given the general metabolic profile of patients complete information regarding the safety aspects of bDMARDs
with PsA which can put them at a higher risk for adverse events is provided in the individual drug’s product information. Costs
such as hepatotoxicity.42–44 The MTX dose should be sufficient, should also be taken into account, but these may vary at the
that is, usually between 20 mg and 25 mg weekly (about 0.3 mg/ country level; cost savings will occur in many countries due to
kg), and use of folate supplementation is recommended to the availability of biosimilar TNF blockers and potentially other
reduce the adverse effects of MTX.45 biosimilars in due course. Personalised medicine, to facilitate an
Other csDMARDs (ie, leflunomide and sulfasalazine) are optimal choice of the first bDMARD, is currently difficult due to
potential treatment options and have demonstrated efficacy in the lack of individualised predictors of response to treatment.55
PsA peripheral arthritis.15 A recent trial of the combination of As previously discussed, it is of key importance to take into
MTX with leflunomide indicated a low efficacy to safety ratio; account the patient phenotype and potential extra-MSK features
thus, this association is not recommended.38 (figure 1). Comorbidities are also to be considered.23 56 More
research is needed on the predictors of drug response, including
the effect of sex.57 58
Recommendation 4
In patients with peripheral arthritis and an inadequate response Combination of a bDMARD with a csDMARD
to at least one csDMARD, therapy with a bDMARD should be First-
line bDMARDs are often given in combination with
commenced. csDMARDs, such as MTX.41 59 However, there are conflicting
This recommendation is relevant to patients with periph- data regarding the added benefit of concomitant MTX with
eral arthritis and therefore is meant to include both those targeted DMARDs in patients with peripheral disease and no
with monoarticular/oligoarticular and those with polyarticular evidence of a benefit of MTX in patients with axial symp-
disease. However, where peripheral involvement is limited toms.33 60 61
and without poor prognostic factors, it is not unreasonable to MTX combination with bDMARDs has been explored mainly
apply a second csDMARD course before initiating a bDMARD/ for TNFi; studies have generally found similar efficacy with
tsDMARD, when this decision is agreed by the prescriber and or without concomitant MTX, although with increased drug
the patient. survival when using MTX, in some studies.41 59 62 A recent large
After failure of at least one csDMARD, the taskforce proposed study reported increased remission rates with TNFi plus MTX
as next step one of the many available bDMARDs (table 1).5 combination therapy.59 With other modes of action, there is a
JAKi is efficacious in PsA, but the taskforce decided that at lack of data to support comedication. Overall, the taskforce
present the efficacy–safety balance, costs and long-term expe- proposed to combine a first bDMARD with the previously
rience with many bDMARDs clearly favour their recommenda- prescribed csDMARD, in all cases where such a treatment has
tion over JAKi. Relevant comorbidities in many patients with already been tolerated by the patient and in particular when the
PsA also favour bDMARD selection. first bDMARD is a TNFi. For other modes of action, given the
Regarding bDMARDs, no order of preference is given since lack of data, we cannot recommend comedication, although the
no bDMARD has demonstrated superiority for joint involve- usual practice would be to continue a csDMARD when initi-
ment over other bDMARDs (table 1).46–48 Herein they are listed ating a bDMARD (doses of the csDMARD can be diminished if
in numeric order of the targeted cytokine, and not in order of needed).
preference. However, in the context of the present recommen-
dation, CTLA4 (cytotoxic T-lymphocyte–associated antigen 4)
inhibition is not considered a good option due to its limited effi- Recommendation 5
cacy in clinical trials.49 The GoR is high for this bullet point, In patients with peripheral arthritis and an inadequate response
reflecting robust accrued data.50 to at least one bDMARD, or when a bDMARD is not appropriate,
Unlike MSK manifestations, non-MSK domains of PsA allow a JAKi may be considered, taking safety considerations into
differential order of bDMARD recommendation (se recommen- account.
dation 9).5 Two head-to-head trials of bDMARDs in PsA, both This recommendation elicited much debate. On the one hand,
comparing an IL-17A inhibitor with adalimumab, showed similar since 2019, new data have accrued on JAKis in terms of efficacy,
efficacy for IL-17A inhibition and TNF inhibition, as regards such as the publication of positive trials on upadacitinib in PsA.63
Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 713
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On the other hand, there is currently a worldwide cautionary entheseal disease without poor prognostic factors and limited
statement issued by both the Food and Drug Administration and skin involvement.9 67 The FOREMOST trial recently confirmed
the European Medicine Agency restricting the use of JAKis in the efficacy of apremilast compared with placebo in oligoartic-
all diseases including PsA, based on an increased risk of cardio- ular PsA.67 Nevertheless, the reason to place apremilast differ-
vascular and malignancy events observed with tofacitinib in ently from bDMARDs or other tsDMARDs is not only based
older patients with RA with cardiovascular risk factors.6–8 JAKis on its consistently relatively low efficacy, but also on the lack of
lead to increased general infection rates of similar magnitude to structural efficacy data (thus putting the term ‘DMARD’ at risk
bDMARDs, but higher for herpes zoster infections.5 Drug safety since there are no data on inhibition of damage progression).
for the JAKis tofacitinib and upadacitinib in the specific context This recommendation received the lowest LoA within the
of PsA was recently reported and appeared reassuring; however, taskforce, reflecting that more than a quarter of the taskforce
follow-up was short and further data are warranted.64 65 While participants were in favour of only discussing apremilast in the

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currently long-term extension data do not show increased cardio- text without a specific bullet point.
vascular/cancer risk related to JAKi use in PsA, there are no RCTs The use of apremilast in combination with TNFi is off-label,
similar to the ORAL-Surveillance trial available at present in PsA. and is a more costly drug combination with no supporting data
Therefore, the taskforce felt that the precautions related to RA and cannot be recommended.
also have to be taken for PsA, especially since various comorbid-
ities important for the JAKi risk profile may be more prevalent
Recommendation 7
in PsA than in RA (eg, obesity and cardiovascular risk factors).
In patients with unequivocal enthesitis and an insufficient
On the other hand, controlling inflammation is important to
response to NSAIDs or local glucocorticoid injections,
decrease cardiovascular risk.
therapy with a bDMARD should be considered.
Safety of JAKis should be carefully considered66; we propose
This bullet point remains unchanged. Unequivocal
in table 2 and figure 1 a shortened version of the EMA warning/
enthesitis refers (as in 2019) to definite entheseal inflam-
limitation to use, which includes age, smoking status and other
mation (which might need additional diagnostic imaging)
cardiovascular/venous/cancer risk factors.7 8
to avoid overtreatment of entheseal pain not related to PsA
After much discussion, we considered that the efficacy–safety
(eg, in the context of widespread pain syndrome or repet-
balance of JAKis did not justify putting JAKis on the same level
itive mechanical stress). 68 69 In terms of treatment options,
as bDMARDs for order of choice (ie, proposing JAKis as usual
the taskforce discussed the recent data indicating indirectly
treatment after insufficient response and/or intolerance to
some efficacy for MTX in enthesitis. 5 38 39 However, it was
csDMARD treatment).
felt that the data for MTX were not sufficiently strong to
Therefore, JAKis are proposed usually as second-line targeted
propose MTX in the bullet point. We do acknowledge that,
therapies (or third- line DMARDs). Of note, we recognise
for some patients with enthesitis, MTX may be an option
that, for some patients, JAKis may be a relevant option after
(figure 1).
a csDMARD; this is reflected in the wording of the bullet For unequivocal predominant enthesitis, the proposal is
point (‘when a bDMARD is not appropriate’). This ‘non- to introduce a bDMARD (without a preference for a specific
appropriateness’ may include contraindications to bDMARDs, mode of action) since all currently approved bDMARDs
practical issues leading to a strong preference for oral adminis- have demonstrated efficacy on enthesitis, with similar
trations (eg, lack of proper conservation at regulated tempera- magnitudes of response, although head-to-h ead trials are
tures) and patient preferences, including risk of non-adherence missing (figure 1). 5 Here, costs may be important, but other
to injections (in accordance with the first OAP concerning shared manifestations will also have to be taken into account (see
decision-making). Nevertheless, patients will have to weigh their recommendations 8 and 9). Of note, although tsDMARDs
preferences against potential risks. are not mentioned specifically in the bullet point, they are
The GoR was low for this recommendation, in particular an option in some cases of enthesitis (always considering
regarding safety considerations, since the data are sparse in benefit to risk ratios, in particular for JAKis). 7 8
PsA and we had to rely on data taken from RA. The taskforce
suggests using JAKi after bDMARDs have failed because several
new bDMARDs with excellent effects on skin involvement and Recommendation 8
relatively good safety data are now available (IL-23, IL-17 inhib- In patients with clinically relevant axial disease with an insuffi-
itors) and more long-term data on JAKi efficacy and safety are cient response to NSAIDs, therapy with an IL-17Ai, a TNFi, an
needed in PsA. The efficacy to safety ratio of JAKis was also put IL-17 A/Fi or a JAKi should be considered.
into the research agenda (table 4). The formulation for axial disease was modified from predom-
Currently, drugs from the tyrosine kinase 2 (TYK2) pathway inant to clinically relevant. For axial disease, in agreement also
inhibition are being assessed in PsA5; they are not currently with the recently updated ASAS/EULAR axSpA recommen-
licensed for use, and indeed the data are at this point limited in dations,33 we continue to judge csDMARDs as not relevant.
particular for safety (including in psoriasis where such therapy bDMARDs targeting TNF and IL-17A and IL-17A/F as well as
is licensed). Thus, we did not include TYK2 inhibition in the tsDMARDs targeting JAK are recommended. For JAKis, safety
current recommendations. issues should be considered. Of note, we propose a choice
between the drugs, not a combination of the drugs.
For this recommendation, the order of the drugs listed is of
Recommendation 6 relevance, meaning that IL-17A inhibition has been put first due
In patients with mild disease and an inadequate response to at to the availability of currently only one trial specifically investi-
least one csDMARD, in whom neither a bDMARD nor a JAKi is gating axial PsA and using secukinumab (the MAXIMISE trial),70
appropriate, a PDE4 inhibitor may be considered. with the other drugs listed thereafter. Thus, the LoE is stronger
This recommendation is unchanged from 2019, with for IL-17A inhibition than for the other drugs, where the data
unchanged LoE. ‘Mild disease’ is defined as oligoarticular or are derived from axial SpA.33
714 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531
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however, given negative trials for IL-12/23 inhibition in axSpA, first element to take into account is the PsA subtype, then as a
the IL-23 pathway is not recommended here.33 71–73 Axial PsA second element extra-MSK manifestations (always considering
remains a challenging form of PsA in terms of definition and safety and comorbidities).
differences with axial SpA; thus, this phenotype is part of the
research agenda (table 4).
Recommendation 10
In patients with an inadequate response or intolerance to a
Recommendation 9 bDMARD or a JAKi, switching to another bDMARD or JAKi
The choice of the mode of action should reflect non- should be considered, including one switch within a class.
musculoskeletal manifestations related to PsA; with clinically This recommendation is unchanged from 2019, with
relevant skin involvement, preference should be given to an unchanged LoE.9 After failing one targeted drug, it is logical to
IL-17A or IL-17A/F or IL-23 or IL-12/23 inhibitor; with uveitis switch to another targeted drug; there are currently no strong
to an anti- TNF monoclonal antibody; and with IBD to an data to prefer a switch with a change in mode of action to a switch
anti-TNF monoclonal antibody or an IL-23 inhibitor or IL-12/23 within the same mode of action. Of note, this recommendation
inhibitor or a JAKi. does not limit the total number of switches for a given patient. It
This is a new recommendation to clarify more visibly than also does not necessarily mean that more switches within a class
in 2019 (table 3) that the choice of drug should take into could not be done, but the taskforce felt that a switch should
account not only the MSK PsA phenotype but also extra-MSK not necessarily be done after one drug of a class has failed.
manifestations. Switches can be made, as appropriate, between bDMARDs, or
The first extra-MSK manifestation of interest in PsA is skin between bDMARDs and JAKis. We include abatacept as a treat-
psoriasis. Although most patients with PsA present with skin ment option (table 1),49 but note that it demonstrated modest
psoriasis or have a personal history of skin psoriasis, registry efficacy and hence this is an option to be used only after failing
data indicate that many patients with PsA have mild skin involve- one or more other targeted drugs. The efficacy of bimekizumab,
ment.74 However, even limited skin psoriasis can be troublesome, the dual IL- 17 A/F inhibitor, appeared similar in TNF- naïve
since relevant skin involvement is defined as either extensive and TNF-experienced populations; this will warrant confirma-
(body surface area involvement >10%), or as important to the tion.53 54 Finally, a combination of bDMARDs is being explored,
patient, that is, impacting negatively their quality of life (such as but cannot be recommended at this time.
is the case with face or genital involvement).9 For these patients,
we recommend preferentially considering drugs targeting the Recommendation 11
IL-17A, IL-17A/F or IL-23 pathway (here, the order between In patients in sustained remission, tapering of DMARDs may be
drugs is cited in order of numbered cytokine, not preference). considered.
There are strong data, including head-to-head trials, in the field This bullet point is unchanged. However, more data have
of skin psoriasis showing that drugs targeting the IL-23 and accrued on tapering, leading to a higher grade of recommenda-
IL-17 pathways are superior to TNFis and to JAKis for skin tion.89–91 By tapering we mean ‘dose reduction’ not drug discon-
psoriasis.51 52 75–78 This justified proposing these modes of action tinuation since the latter usually leads to flares. Drug tapering
preferentially in case of relevant skin involvement. This is in is a logical step when patients are doing well over time, from
keeping with psoriasis recommendations.79 a safety and a cost perspective (tapering is often performed by
Uveitis is not as frequent in PsA as it is in axial SpA; the prev- the patient himself/herself alone). On the other hand, long-term
alence is reported around 5%.80 However, uveitis can be severe data are missing and currently drug tapering is off-label. For all
and should influence treatment decisions. Currently, the only of these reasons, the taskforce kept the tentative wording of
mode of action with direct proof of efficacy on uveitis is TNF ‘may be considered’ (to ensure it is not made mandatory) and of
inhibition through monoclonal antibodies (ie, adalimumab and course in the context of a shared decision with the patient (as is
infliximab). Thus, for patients with uveitis, an anti-TNF mono- the case also for the other treatment decisions).
clonal antibody is preferred.
Inflammatory bowel disease (IBD) concerns 2%–4% of
patients with PsA.80 The armamentarium for IBD has widened Research agenda
recently, and this recommendation reflects this fact, proposing The taskforce felt that many issues needed more data, and an
that one of the modes of action currently licensed for IBD extensive research agenda was developed (table 4).
should be prescribed when it coexists with PsA. No order of
preference is given here and prescribers are urged to adhere to DISCUSSION
EMA authorisations for IBD and take into account safety. For This paper presents updated recommendations for the manage-
informative purposes, as of mid-2023, drugs authorised for IBD ment of PsA, a treatment algorithm and a research agenda. This
include anti-TNF monoclonal antibodies (ie, adalimumab and update addresses all currently available drugs and modes of
Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 715
Recommendation

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4
rests on data related to efficacy, clinical phenotype, adverse Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher
School of Nursing of Lisbon, Lisbon, Portugal
event risk profile, tolerance, long-term data, cost and access. 5
Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE,
While laboratory biomarkers for stratified treatment approaches Coimbra, Portugal
6
are lacking, the taskforce used clinical markers to develop clin- 7
Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Herne, Germany
ical phenotypic preferences for specific drugs. In these updated EULAR Patient Research Partner, EULAR, Oslo, Norway
8
Dermatology and Venereology, Geneva University Hospitals, Geneva, Switzerland
recommendations, the taskforce applied expert opinion to the 9
Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine
available data, to propose a pragmatic, logical order of a step-up Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
approach to targeted treatments of PsA. The taskforce felt that 10
Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
11
proposing an order is helpful both for clinicians and to advocate College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow,
for access to drugs for patients with PsA. UK
12
LTHT, NIHR Leeds Biomedical Research Centre, Leeds, UK
The drug options considered in these recommendations are 13
Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds,
currently licensed for PsA. We are aware that other drugs are Leeds, UK
14
being tested, or are available in other related conditions, espe- Division of Infectious Diseases, School of Medicine, School of Public Health, Oregon
cially skin psoriasis; however, these drugs are considered out of Health & Science University, Portland, Oregon, USA
15
Sf Maria Hospital, University of Medicine and Pharmacy Carol Davila Bucharest,
the scope of the present recommendations. Brodalumab was at Bucharest, Romania
the time of these recommendations only approved for psoriasis; 16
Medical Imaging Centre, Semmelweis University, 3rd Rheumatology Department,
TYK2 inhibitors such as deucravacitinib and brepocitinib have National Institute of Musculoskeletal Diseases, Budapest, Hungary
17
also been developed or in development for skin psoriasis and PsA; Department of Rheumatology and Clinical Immunology, Freie Universität Berlin and
izokibep is a novel antibody mimetic, a small IL-17i currently Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
18
Arthritis Unit, Department of Rheumatology, Hospital Clínic Barcelona, Barcelona,
undergoing testing; and an oral IL-23i is also in development.5 Spain
The taskforce had extensive discussions on the positioning 19
FCRB, IDIBAPS, Barcelona, Spain
of JAKi in the recommendations.63 92 We as a group feel that
20
Rheumatology, AP-HP, Henri Mondor University Hospital, Creteil, France
21
it is important to make haste slowly, and to uphold high safety EA Epiderme, UPEC, Creteil, France
22
Department of Medicine, University of Toronto, Women’s College Hospital, Toronto,
standards when promoting drugs with only short-to-medium- Toronto, Canada
term experience and for which long-term data are lacking—not 23
The Copenhagen Center for Arthritis Research, Center for Rheumatology and
least in PsA. In fact, this cautious attitude was also adhered to Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup,
in the 2019 recommendations, and further safety developments Denmark
24
have later confirmed that this attitude was appropriate.7 8 It is of Department of Clinical Medicine, Faculty of Health and Medical Sciences, University
of Copenhagen, Copenhagen, Denmark
key importance to continue monitoring the drugs and, ideally, 25
Academic Rheumatology Centre, Dipartimento Scienze Cliniche Biologiche,
perform controlled trials, as only hard and high-level data can Università di Torino - AO Mauriziano Torino, Turin, Italy
26
be reassuring. 27
The Parker Institute, Bispebjerg, Denmark
Costs are also an important aspect in patient management, Frederiksberg Hospital, Copenhagen University, Copenhagen, Denmark
28
Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering
and it is generally recommended to prescribe the cheaper Research Center, KU Leuven, Leuven, Belgium
drug if two agents have similar efficacy and safety. Of note, 29
Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
even if one mode of action may have somewhat better effi- 30
Rheumatology, Hospital Universitario Central de Asturias, Oviedo, Spain
31
cacy on certain manifestations, a less expensive agent could Translational Immunology Division, Biohealth Research Institute of the Principality
still be preferred as long as it does not bear much lesser of Asturias, Oviedo University School of Medicine, Oviedo, Spain
32
Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples,
efficacy in that disease domain. Biosimilars are available for Italy
several TNFis and have led to significant reduction in expen- 33
Rheumatology Research, Providence Swedish, Seattle, Washington, USA
34
diture and more use in many countries, while their price 35
University of Washington School of Medicine, Seattle, Washington, USA
is not much lower than that of originators in many other School of Medicine, Griffith University, Brisbane, Queensland, Australia
36
Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg,
ones. Tofacitinib will soon become generic, and the same is The Netherlands
true for apremilast, which should also lower the costs for 37
Young PARE Patient Research Partner, EULAR, Zurich, Switzerland
these agents and allow wider application especially in less 38
School of Medicine and Dermatology, Leeds Teaching Hospitals NHS Trust,
affluent countries. Thus, overall, the taskforce felt that the University of Leeds, Leeds, UK
39
prescription of drugs would account for the relationships Department of Internal Medicine 3, Rheumatology and Immunology and
Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg,
between efficacy, safety and cost, in line with the OAPs and Erlangen, Germany
the 11 recommendations which are summarised in the algo- 40
Children and Young Person’s Rheumatology Research Programme, Centre for
rithm (figure 1). Many points are still to be confirmed in Musculoskeletal Research, The University of Manchester, Manchester, UK
41
the management of PsA, leading to an extensive research First Department of Internal Medicine, University of Occupational and
Environmental Health, Japan, Kitakyushu, Japan
agenda. 93 42
Department of Internal Medicine and Pediatrics, VIB Center for Inflammation
In conclusion, the updated 2023 recommendations should Research, Ghent University, Gent, Belgium
be helpful to clinicians but also to health professionals and 43
Rheumatology, Leiden University Medical Center, Leiden, The Netherlands

716 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531

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Ann Rheum Dis: first published as 10.1136/ard-2024-225531 on 18 March 2024. Downloaded from http://ard.bmj.com/ on August 23, 2025 at Bangladesh: BMJ-PG Sponsored
44
Department of Medical and Biological Sciences, Azienda sanitaria universitaria British Society for Medical Dermatology (BSMD) Committee. GS: honoraria: Novartis,
Friuli Centrale, Udine, Italy Janssen. SJWS-W: grant support: Medical Research Council (MR/W027151/1). YT:
X Laure Gossec @LGossec, Ricardo J O Ferreira @FerreiraRJO, Lihi Eder @lihi_eder, research grants from Mitsubishi Tanabe, Eisai, Chugai, Taisho; speaking fees and/or
Daniele Mauro @dranielmar, Peter Nash @drpnash and Stephanie J W Shoop- honoraria from Eli Lilly, AstraZeneca, AbbVie, Gilead, Chugai, Boehringer Ingelheim,
Worrall @sshoopworrall GlaxoSmithKline, Eisai, Taisho, Bristol Myers, Pfizer, Taiho. FEVdB: consultancy
honoraria from AbbVie, Amgen, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB.
Contributors All authors have contributed to this work and approved the final AZ: speakers bureau: AbbVie, Novartis, Janssen, Lilly, UCB, Amgen; paid instructor
version. for AbbVie, Novartis, UCB. DvdH: consulting fees AbbVie, Argenx, Bayer, BMS,
Funding Supported by EULAR (QoC016). Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Takeda, UCB
Pharma; Director of Imaging Rheumatology bv; Associate Editor for Annals of the
Competing interests No support to any author for the present work. Outside the Rheumatic Diseases; Editorial Board Member for Journal of Rheumatology and RMD
submitted work: LG: research grants: AbbVie, Biogen, Lilly, Novartis, UCB; consulting Open; Advisor Assessment Axial Spondyloarthritis International Society. JSS: research
fees: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, MSD, Novartis, Pfizer, UCB; grants from AbbVie, AstraZeneca, Lilly, Galapagos; royalties from Elsevier (textbook);

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non-financial support: AbbVie, Amgen, Galapagos, Janssen, MSD, Novartis, Pfizer, consulting fees from AbbVie, Galapagos/Gilead, Novartis-Sandoz, BMS, Samsung,
UCB; membership on an entity’s Board of Directors or advisory committees: EULAR Sanofi, Chugai, R-Pharma, Lilly; honoraria from Samsung, Lilly, R-Pharma, Chugai,
Treasurer. AK: speakers bureau, consultancy: AbbVie, Amgen, Galapagos, Janssen, MSD, Janssen, Novartis-Sandoz; participation in advisory board from AstraZeneca.
Eli Lilly, MSD, Novartis, Pfizer, UCB. RJOF: research grants: Medac, Lilly; consulting
fees: Sanofi. DA: research grants: Galapagos, Lilly; consulting fees: AbbVie, Gilead, Patient consent for publication Not required.
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Medac, Sandoz; advisory board: AbbVie; past-chair of the steering committee of the
Danish Rheumatology Quality Registry (DANBIO, DRQ), which receives public funding
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Handling editor Dimitrios T ABSTRACT INTRODUCTION

Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 709

 New 9 The choice of the mode of action should reflect non-­

D. The primary goal of treating patients with psoriatic Recommendations

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716 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531

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718 Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531

Gossec L, et al. Ann Rheum Dis 2024;83:706–719. doi:10.1136/ard-2024-225531 719

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