Available evidence supports first-line treatment with sulfasalazine, leflunomide, methotrexate, and cyclosporine, Christopher T. Ritchlin, M.D., of the University of Rochester, and his colleagues on an international panel of arthritis specialists advised in the online version of Annals of the Rheumatic Diseases.
- Explain to patients that there are now evidence-based guidelines for diagnosis and treatment of psoriatic arthritis.
Other treatment options include nonsteroidal anti-inflammatory drugs, intra-articular steroid injections, and tumor necrosis factor inhibitors.
The panel recommended against use of systemic corticosteroids, gold salts, chloroquine, and hydroxychloroquine.
"Treatment recommendations for the cardinal physical manifestations of [psoriatic arthritis] were developed based on a literature review and consensus between rheumatologists and dermatologists," the guideline authors wrote.
Of the 19 recommendations in the guidelines, 16 are backed by greater than 80% agreement. The guidelines include a grid to assist clinicians in clinical decision-making for individual patients.
Specific recommendations include:
- Diagnosis by Classification Criteria for Psoriatic Arthritis (CASPAR), which require a total of three points from the following: two points for current psoriasis and one point each for history of psoriasis, family history of psoriasis, nail changes, dactylitis, juxta-articular new bone on radiographs, and rheumatoid factor negativity
- An assessment that should include evaluation of peripheral joints, pain, patient-rated global assessment, health-related quality of life, fatigue, acute phase reactants, radiography as indicated by clinical findings, and findings that predict a poor prognosis (progression of peripheral joint disease and damage, elevated erythrocyte sedimentation rate, drug-refractory disease, presence of damage by clinical or x-ray findings, loss of function, and reduced quality of life)
- Input from a rheumatologist when beginning treatment with a disease-modifying antirheumatic drug (DMARD)
- DMARD failure defined as one drug or a combination given a three-month trial, including two months at a standard dose
- Consideration of anti-TNF agents after DMARD failure
The authors acknowledged that treatment decisions have been complicated by a "paucity of adequately powered placebo-controlled clinical trial data for some of the most common agents used in the treatment of [psoriatic arthritis], most notably methotrexate."
The panel emphasized that treatment recommendations should be developed with input from rheumatologists and dermatologists.