November 10-15

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ACR Convergence 2023

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New management guideline for PsA uses GRADE methodology


3 minutes

The ACR is about to release its first-ever guideline for the management of psoriatic arthritis (PsA). Written in conjunction with the National Psoriasis Foundation (NPF), the guideline is designed for rheumatologists, but also will be helpful for dermatologists, primary care providers, and other healthcare professionals who care for patients with PsA.

Alexis Ogdie, MD, MSCE
Alexis Ogdie, MD, MSCE

“These guidelines are different from existing guidelines for the management of PsA,” said Alexis Ogdie, MD, MSCE, Assistant Professor of Medicine at the University of Pennsylvania Perelman School of Medicine. “These are the first PsA guidelines written using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology the ACR has used for rheumatoid arthritis and other conditions. And they are the first guidelines developed with the U.S. healthcare system and payers in mind.”

Dr. Ogdie will start the special clinical symposium Treatment of Psoriatic Arthritis: 
A New ACR/NPF Clinical Guideline on Tuesday from 1:00 – 2:00 pm in Room 30 E. She will discuss the GRADE methodology and literature review that formed the basis of the ACR/NPF guideline. Jasvinder Singh, MD, MPH, Professor of Medicine at the University of Alabama at Birmingham School of Medicine, will present the draft recommendations from the guideline. Evan Siegel, MD, Medical Director of Arthritis and Rehabilitation Therapy Services for Arthritis and Rheumatism Associates in Washington, D.C., will discuss several PsA cases in light of the new guideline.

Jasvinder Singh, MD, MPH
Jasvinder Singh, MD, MPH

The GRADE methodology evaluates the quality of evidence and strength of recommendations that are based on that evidence. The approach is designed to enhance transparency in the evaluation of evidence and ways in which evidence is used to construct recommendations for or against any particular management option.

“This guideline simplifies treatment of a very complex disease with a new algorithm that incorporates non-pharmacologic and pharmacologic treatments, including new biologics for the management of active disease,” Dr. Singh said. “This is the best synthesis of the evidence we have to date on the management of PsA.”

Clinicians can expect distinct management recommendations for different PsA presentations. The condition typically presents as enthesitis or axial disease, but there are also peculiarities specific to spondyloarthropathy and spondyloarthritis that are relevant to PsA.

The guideline also recognizes that PsA seldom presents on its own. Patients and clinicians typically deal with multiple comorbidities that include diabetes, a history of recurrent infections, inflammatory bowel disease, and more. All of these comorbidities can and should play a role in management decisions.

Those management decisions have become more complex given the range of new therapies and approaches that have been developed in recent years, Dr. Singh said. The new guideline will help bring the most important management considerations into sharper focus.

Treat to target has emerged as an important new concept in the management of PsA and related rheumatologic conditions. The GRADE methodology has produced a robust evidence-based approach to the treatment of PsA that the profession has ever seen.

Look for a similar evidence-based approach to treatment selection and treatment options for patients with active disease who fail one or more standardized approaches.

The guideline also introduces new nomenclature. Traditional disease-modifying antirheumatic drugs, or DMARDs, have been renamed oral small molecules, or OSMs, to more clearly distinguish them from biologic agents.

Only the name for the general treatment category has changed, Dr. Singh said. The most common oral agents involved, methotrexate, sulfasalazine, apremilast, hydroxychloroquine and azathioprine, are the same under the older DMARD label or the current OSM usage.

“We have never had this kind of standardized, evidence-based methodology and we hope this guideline becomes instrumental in leading the improvement in care for PsA,” Dr. Singh said. “This new guideline is patient- and clinician-centered and brings new insight into the management of our patients.”