Expert Review of New PsA Guidelines and the Impact on Care

Vikas Majithia, MD, professor of medicine as well as division chief and fellowship program director in the division of rheumatology at University of Mississippi Medical Center in Jackson, Mississippi, discusses the new psoriatic arthritis guidelines for clinical practice that were developed as a joint effort by the American College of Rheumatology and National Psoriasis Foundation.

First Report Managed Care:  With us today is Dr. Vikas Majithia, who is professor of medicine as well as division chief and fellowship program director in the division of rheumatology at University of Mississippi Medical Center in Jackson, Mississippi.

He is with us today to discuss the new psoriatic arthritis guidelines for clinical practice, that were developed as a joint effort by the American College of Rheumatology and National Psoriasis Foundation.

Thank you for joining us today, Dr Majithia.

What do you think are the most important points in the new psoriatic arthritis guidelines?

Dr Majithia:  As I review these guidelines I find that the two most important things which were addressed in these guidelines were, first, a recommendation to use treat to target approach for all patients with active Psoriatic Arthritis. Which implies that we have to try to target to go ahead and adjust the therapy to get the patients into low disease activity or remission and continually monitor them periodically and adjust it till we actually achieve that goal.

This strategy has been well established and used in rheumatoid arthritis, but these are the first set of guidelines which address using them in treatment and management of patients with psoriatic arthritis.

The second important point which I really want to emphasize is that the guidelines recommend in treatment naive active psoriatic arthritis patients, use of tumor necrosis factor inhibitor biologics, TNF alpha inhibitors as first line therapy option in patients with active psoriatic arthritis.

These are recommended above and over use of a DMARD, disease-modifying antirheumatic agents or oral small molecules as a first line therapy.

That's a huge change from the previous approach than strategy that we are typically used to. That means that right now when we see a patient with psoriatic arthritis, we would lot of times try a DMARD or oral small molecules except when they have spinal or axial disease.

These guidelines address that using a TNF biologic may be more appropriate in these patient than trying those currently well accepted ways of management.

First Report Managed Care:  What do you think about the methodology used to develop the guidelines? Do you think it leads to a reliable set of recommendations?

Dr Majithia:  This is a really great question. These guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Also, in short called as GRADE methodology.

This is the most accepted and strongest way of formulating guidelines. It is based on review of currently available data. It tends to remove a lot of bias that lot of us experts might have when we are developing these guidelines.

The only downside is there is limited data in a number of areas as evidence and as seeing these guidelines, which is, the quality of evidence is often graded low or very low.

This leads to recommendations being conditional. This was seen in these guidelines that 94 percent of these recommendations were conditional and only six percent was strong. On the other hand, this gives us the best set of guidelines or recommendations which can be applicable to management of these patients and they are very reliable to follow.

It also gives us a framework to refer to in various circumstances and not be bound to them as it gives a lot of choices and availability of alternate options if we are using this methodology.

This methodology also gives us strong framework to refer to various circumstances when the evidence is not strong enough to be able to make choices as practicing physician at patient's bedside or in the clinic and not to be tied with only one single way of managing these patients.

Another strength which I really felt regarding these guidelines was that the voting panel here included not only rheumatologists but also dermatologists, other health professionals and patients which helped achieve getting everybody's input into making these guidelines and developing a consensus which is more likely to be applicable to the real patient we've seen in a day to day practice.

First Report Managed Care:  What do the guidelines recommend about the role of small molecules in the treatment of Psoriatic Arthritis?

Dr Majithia:  The oral small molecules which are being referred to in these guidelines are methotrexate, sulfasalazine, cyclosporine, leflunomide and apremilast. These molecules maybe used instead of a TNF inhibitor biologic in patients without severe psoriatic arthritis and without severe psoriasis or also in those who prefer an oral drug instead of parenteral therapy.

They can also be used in those who have contraindications to TNF inhibitor treatment such as congestive heart failure, previous serious infection, recurrent infections or demyelinating disease.

Just to clarify this oral small molecule category did not include tofacitinib because of its risk of having...profile being very different than traditional disease modifying oral small molecules.

First Report Managed Care:  Psoriatic arthritis patient can experience different manifestations. Do these guidelines have any specific recommendations for this?

Dr Majithia:  That's another great question. Psoriatic arthritis patients do develop enthesitis and dactylitis as a manifestation which is very specific in patients with spondyloarthritis and more so in psoriatic arthritis patients.

These guidelines do recommend that in a patient with treatment-naive psoriatic arthritis, patients with predominant enthesitis, a TNF inhibitor biologic is the way to go over use of an oral small molecule as a first line option. Because that has some strongest evidence of giving benefit to these patients.

Interestingly, apremilast may also be used in these patients instead of a TNF inhibitor biologic if the patient prefer an oral therapy or has contraindications to TNF inhibitors, as that is the only oral small molecule which has shown to have some benefit in patients with enthesitis.

First Report Managed Care:  The guidelines do not address obesity management in great detail. Is this something that should have been expanded upon?

Dr Majithia:  Obesity manage was addressed in a very short way in these guidelines, and they did recommend considering weight loss options, but not have a strong recommendation.

They also give an option that weight loss program may not be concomitantly prescribed because of possible additional costs which in my opinion should have been addressed a little bit more in detail.

I think the weight loss and obesity management is huge part of management of psoriatic arthritis because of its benefits physically it has provided.

In addition, a metabolic benefit which is provided by weight loss by decreasing the inflammatory milieu in these patients. So I would like to see a strong recommendation and better direction given to obesity management in guidelines which are somehow not there.

The other strong set of recommendation we did come out of the guideline was smoking cessation, which I absolutely love and that is something we should be addressing on every patient with psoriatic arthritis, because patients who smoke tend to have worst disease and poor outcomes.

First Report Managed Care:  What are the additional areas covered in the guidelines that can be beneficial for practicing physicians?

Dr Majithia:  The guidelines provided evidence based pharmacological and nonpharmacologic recommendations in management of psoriatic arthritis, but they also address other areas like vaccinations in these patients.

How do we manage psoriatic arthritis in presence of inflammatory bowel disease or if patients have diabetes, which is fairly common in patients who have psoriatic arthritis? How do we manage these patients with concomitant or recent serious infections?

Hence, these guidelines are a huge step forward in progressing day to day management in patients with psoriatic arthritis.

First Report Managed Care:  What is the key takeaway for rheumatologists to know about the new psoriatic arthritis guidelines?

Dr Majithia:  Psoriatic arthritis patients should be managed using a treat-to-target strategy. We should aim to get the disease under control, get them to a least to low disease activity or more likely aim for remission and try to adjust and/or escalate their therapy unless they have met these targets.

The second big takeaway is that TNF inhibitors as biologic can be used as first line therapy above and beyond the use of a DMARD or oral small molecules.

Last strong takeaway is that smoking cessation and smoking counseling is a must in these patients who have active psoriatic arthritis at least to likely significant improvement in their outcomes.

Thank you.