Priority 1 from the Psoriatic Arthritis PSP

UNCERTAINTY: What is the best strategy for managing patients with psoriatic arthritis, including non-drug and drug treatments?  (JLA PSP Priority 1)
Overall ranking 1
JLA question ID 0108/1
Explanatory note The purpose of this question is to explore the best treatment options that healthcare professionals and people living with psoriatic arthritis can use. There is uncertainty about the overall best strategy for choosing and guiding treatments and the efficacy of combining non-drug and drug treatment choices. In some drug treatment and most non-drug treatments, there is a lack of an evidence to guide how best to use them. For example, psychological interventions, exercise, physiotherapy, occupational therapy and podiatry. Uncertainties that reflect this question included, what is the best way to control it? How can psoriatic arthritis be managed better? When should steroids be offered? Why are more treatments that are not medication, but which have proved beneficial, not offered? e.g. hydrotherapy, psychological support. 

This question has been partially addressed in the evidence base from the following systematic reviews and guidelines:

Almodovar, 2018. Weight loss in PsA could be associated with less inflammation; however, the evidence to support this is limited. Patients who managed to lose weight-by any method-had better results in terms of activity and inflammation. The percentage of weight loss correlated moderately with changes in inflammatory outcomes. More research needed
Abdelghani, 2020. A review of rheumatic inflammatory diseases including PsA. Limited evidence to suggest US-guided injection in retroclacneal bursistis with a lateral approach was beneficial in terms of preventing side effects
Venegas-Iribarren, 2018. Ustekinumab leads to clinical improvement in psoriatic arthritis, and probably is not associated to severe adverse effects
Torres, 2021. Evidence for psoriatic disease (including psoriasis and peripheral arthritis. Secukinumab and ixekizumab were the treatments with the highest probability of reaching both PASI100 and ACR70 outcomes. Due to the lack of a standard evaluation of outcomes of the other psoriatic disease domains, a network meta-analysis for all the domains was not possible to perform
Pham, 2019. Two head-to-head trials show no difference between ixekizumab and adalimumab or adalimumab and tofacitinib for TOA-ACR outcomes. For PASI75, ixekizumab had a faster onset than adalimumab. Infliximab plus MTX was faster than MTX alone. Pooled results from 32 study arms for TOA-ACR20 (week [95% CI]) are: < 2 weeks: infliximab (1.18 [0.72-1.65]), ixekizumab (1.04 [0.80-1.28]), tofacitinib (10 mg 1.56 [1.14-1.98]); <= 4 weeks: adalimumab (1.95 [1.35-2.55]), secukinumab (75 mg 1.89 [0.16-3.62], 150 mg 2.13 [1.34-2.91], 300 mg 2.26 [1.75-2.76]), tofacitinib (5 mg 2.20 [1.41-2.99]); 4 + weeks: apremilast, ustekinumab. For TOA-ACR50, all pooled point estimates are > 4 weeks. For TOA-PASI75, the range is between 2.24 [1.65-2.84] for ixekizumab and 6.03 [3.76-8.29] for adalimumab. Indirect, mixed comparison suggest a faster onset of infliximab, ixekizumab and tofacitinib compared to apremilast, methotrexate and ustekinumab for ACR20, not ACR50. For PASI75, ixekizumab is faster than adalimumab. Further research needed
Pflugbeil, 2020. A concise overview on drug-drug interactions is given. Especially in more sophisticated cases extensive knowledge of drug interactions supports optimisation of therapy and results in improved patient safety. pharmacotherapy in the treatment of inflammatory arthritis is quite safe and well evidence-based
Helliwell, 2019. A structured literature review suggested to improve disease monitoring a full disease assessment should be carried out annually and short term unscheduled appointments should be available within 2 weeks
Gossec, 2019. Ten recommendations regarding adherence. Key points include that adherence should be assessed at each outpatient visit, at least using an open question; questionnaires and hydroxychloroquine blood level assessments may also be useful. Risk factors associated to non-adherence were listed. Patient information and education, and patient/physician shared decision, are key to optimize adherence. Other techniques such as formalized education sessions, motivational interviewing and cognitive behavioral therapy may be useful. All health professionals can get involved and e-health may be a support
Dressler, 2019. For ACR20/50, HAQ-DI and SF-36, the active treatment was efficacious and the quality of the evidence was mostly moderate to low (15 of 18 comparisons). The quality of evidence for (serious) adverse events was mostly low; differences were rare. In three placebo-controlled comparisons, leflunomide, MTX and sulfasalazine failed to show statistical superiority for ACR. Besides the established treatment of anti-TNF antibodies and ustekinumab for psoriatic arthritis, the newer treatment options of IL17 antibodies and apremilast are also effective for the treatment of psoriatic arthritis. Based on just one comparative trial and one drug each, the new class of anti-IL 17 antibodies appears to be equally effective as the group of anti-TNF antibodies; for apremilast, this is yet unclear
Ureyen, 2018. There is evidence in the literature to guide clinicians on how to treat PsA patients with polyarticular disease, but there is a gap in knowledge about the other subtypes
Wu, 2018. Secukinumab may be the safest and most efficacious short-term treatment for peripheral PsA among all the new biologics targeting IL-6, IL-12/23 and IL-17 pathways
Gladman, 2020. Tofacitinib provides an additional treatment option for patients with psoriatic arthritis, both in patients naïve to TNFi and in those with TNFi-IR
NICE, 2018. Adults with axial spondyloarthritis are referred to a specialist physiotherapist for a structured exercise programme

Health Research Classification System category Inflammatory and immune system
Extra information provided by this PSP
Original uncertainty examples What is the best way to control it? 
Submitted by 77 uncertainties submitted 
PSP information
PSP unique ID 0108
PSP name Psoriatic Arthritis
Total number of uncertainties identified by this PSP. 46  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 12 July 2021