The New ACR/NPF Guidelines: A Rheumatologist’s Perspective
We are in a very exciting time for the treatment of psoriatic arthritis (PsA) and psoriasis with the availability of multiple effective agents, and more in the pipeline, to treat these disorders. The new ACR/NPF guidelines probably will not tremendously alter the way most rheumatologists treat patients with PsA.1 However, they do provide several helpful definitions of disease activity and a framework and paradigm for treatment in a variety of situations that are both routine and clinical challenges. Additionally, they provide guidance for quality care relating to preventative care and lifestyle issues.
Definitions for both severe PsA and psoriasis are provided along with a definition for active PsA. The treatment recommendations have received some criticism due to their “conditional” nature under the GRADE system of evaluating such recommendations. This is due to the low quality of available literature-based evidence to support some of the findings in specific clinical scenarios. Each conditional recommendation was felt by the panel to have desirable effects outweighing undesirable effects based on the literature available.1
Perhaps the most controversial and most impactful recommendation for the treatment of PsA is the recommended use of a tumor necrosis factor (TNF) inhibitor as first line therapy for treatment-naïve patients with active PsA. TNF inhibitors were recommended over the use of oral small molecule-based drugs, such as methotrexate, for the first time in any published guidelines. While many rheumatologists have been attempting to use TNF inhibitors as first line treatment, they have encountered several obstacles due to lack of prior guideline recommendations and therefore great difficulty in getting insurance coverage. This should make that process easier.
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Guidelines on therapies include flow charts for therapy recommendations making treatment decisions for many common clinical situations that arise clearer. These include treatment-naïve patients, patients who have already failed treatment with an oral small molecule, those that have failed a TNF inhibitor, IL17 and IL12/23 inhibitors.
Additionally, specific domains are addressed. For example, patients with spondylitis should be treated with a TNF inhibitor over an IL17 inhibitor unless they have severe psoriasis. Caveats for each of these recommendations with different options for treatment, such as the aforementioned example, are included to allow discussion between physician and patient and for comorbid contraindications. This certainly facilitates patient care and physician-patient dialogue.
The guidelines address the important area of comorbid conditions. Some of the few strong recommendations in these guidelines are in this area. In patients with PsA and concomitant inflammatory bowel disease, it is strongly recommended to choose a monoclonal type TNF inhibitor or an IL 12/23 inhibitor over a soluble receptor anti-TNF or an IL17 inhibitor. In patients with recurrent infections, it is strongly recommended to use an oral small molecule medication over a TNF inhibitor. These are important clinical scenarios given the frequency of comorbidities in patients with PsA.
Several practical and lifestyle recommendations are also included to help in the care of these patients. It is recommended that treatment with biologics not be delayed in patients requiring non-live vaccines, but delayed if possible for live vaccines. Smoking cessation was another strong recommendation. A number of recommendations for non-pharmacologic interventions were also made, which should be considered by all rheumatologists caring for patients with PsA for completeness of care.
In summary, these new guidelines give a roadmap for therapy in nearly all clinical situations that would arise in the treatment of patients with PsA. They should serve as a reference for evidence-based treatment of this sometimes difficult to treat population at risk for disability with delay of therapy. These guidelines should further provide evidence to help secure access for patients to needed therapies. Review by dermatologists should underscore the need for close coordination of care between dermatology and rheumatology in these conditions.
Dr Siegel is a board-certified rheumatologist and assistant clinical professor of medicine at Georgetown University School of Medicine in Washington, DC.
1. Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis. Arthritis Rheumatol. 2019;71(1):5-32.