Use of disease-modifying antirheumatic drugs like methotrexate, sulfasalazine, and leflunomide may improve the outcome of severe psoriatic arthritis if they are given earlier in the course of the disease.
That is one of the recommendations from a new set of guidelines on the treatment of psoriatic arthritis (PsA), issued by a European League Against Rheumatism (EULAR) task force and published online Sept. 27 in Annals of the Rheumatic Diseases.
Dr. Laure Gossec
According to Dr. Laure Gossec, lead author of the report, the recommendations from 28 rheumatologists, 2 patients, an infectious disease specialist, a dermatologist, a physiotherapist, and 2 rheumatology fellows are meant to offer some guidance for what is often a "clinically heterogeneous" disease with few available high-quality studies.
"The treatment of psoriatic arthritis has changed dramatically over recent years, despite the lack of sufficient knowledge on etiology and detailed pathogenesis," wrote Dr. Gossec of Paris Descartes University and colleagues (Ann. Rheum. Dis. 2011 [doi:10.1136/annrheumdis-2011-200350]).
And although the new guidelines "reflect the current state of evidence and thought in the area of PsA management, ... several of the recommendations are strongly based on expert opinion, which in turn is based on clinical practice that has emerged in certain institutions, rather than available evidence," wrote the authors. "This is due to the paucity of data in the field of PsA."
The first recommendation, agreed upon unanimously by the task force, is that "in the vast majority of PsA patients, NSAIDs [nonsteroidal anti-inflammatory drugs] should be used as first-line treatment, although the data regarding the usefulness of NSAIDs in PsA are limited."
The task force conceded that in the setting of cardiovascular or gastrointestinal disease, these drugs, including cyclooxygenase-2 inhibitors – which data suggest are as effective as nonselective NSAIDs for PsA – may not be appropriate.
A second recommendation concerned the "early" use of disease-modifying antirheumatic drugs (DMARDs), specifically within 1 year of diagnosis for patients with active disease (i.e., one or more inflamed/tender joints) whose symptoms are unrelieved by NSAIDs.
However, "regarding the choice of a DMARD, here again there are few data and almost no head-to-head comparisons," wrote the authors.
Nevertheless, "the experts recommended methotrexate as the first-choice DMARD ... based in particular on broad therapeutic dose ranges, different application forms [oral or subcutaneous preparations], and available data in PsA and in other inflammatory diseases."
"In the vast majority of PsA patients, NSAIDs should be used as first-line treatment."
"Transaminase enzymes should be carefully monitored in patients with PsA who receive treatment with methotrexate or leflunomide," especially in the setting of comorbid alcohol abuse, diabetes, or statin therapy, they added.
The authors also weighed in on the use of steroids, especially in localized disease. "Intra-articular steroids are efficacious for mono/oligoarthritis or single joint flares in otherwise well-controlled polyarthritis," they wrote. Systemic steroid use, however, should be undertaken with caution, in light of case reports of skin flares that occur at the time of tapering. And when doses are being tapered, "attention should be paid to the potential worsening of skin disease (rebound)," they added.
Finally, the group addressed the use of tumor necrosis factor inhibitors, which can be considered in the event of "treatment failure," defined as an inability to reach target low disease activity after 3-6 months of treatment. In a very few patients, TNF inhibitors may be considered as a first-line treatment in DMARD-naive patients with very active disease. This recommendation is based entirely on expert opinion; there are no data to support it.
"TNF inhibitors (adalimumab, etanercept, golimumab, and infliximab) have demonstrated efficacy in PsA, both for skin and joint involvement, as well as in preventing radiographic damage," wrote the authors.
They added: "This information may be taken into consideration for the choice of TNF inhibitors in patients with clinically significant skin involvement."
The development of the recommendations was sponsored by EULAR. Several of the authors of this article disclosed financial relationships to numerous pharmaceutical companies and the makers of drugs used in PsA treatment.