The draft revision of EULAR’s recommendations for managing psoriatic arthritis sticks with the group’s already-existing conviction that psoriatic arthritis treatment
best starts with an NSAID, and if
that fails follow with a conventional
synthetic antirheumatic drug such as
methotrexate, a position in stark contrast with the 2018 recommendation
from the American College of Rheumatology to first treat with a tumour
necrosis factor (TNF) inhibitor.
For patients with psoriatic arthritis
(PsA) manifesting with polyarthritis,
conventional synthetic disease-modifying antirheumatic drugs (
csDMARDs) “should be first,” and
should “start rapidly” if brief, initial
treatment with an NSAID proves
inadequate, Prof. Laure Gossec said
while presenting a draft version of an
update to the EULAR PsA management recommendations at the European Congress of Rheumatology.
The EULAR recommendations-revi-sion panel had about the same advice
for managing PsA patients with oligo-arthritis, monoarthritis, or peripheral
arthritis. For oligo- and monoarthritis,
“consider a csDMARD after failing
NSAIDS, but also consider the patient’s prognostic factors,” like structural damage, and dactylitis. For PsA
patients with peripheral arthritis, “it
still makes sense to keep csDMARDs
as the first-line treatment,” said Prof.
Gossec, professor of rheumatology at Pitie-Salpétriere Hospital and
Sorbonne University, Paris. Once
published, the revision will replace
existing EULAR recommendations
from 2015 (Ann Rheum Dis. 2016
The list of csDMARDs she cited in-
cluded not just methotrexate, still the
top csDMARD, but also sulfasalazine
and leflunomide as alternatives, she
noted, with methotrexate also the
preferred csDMARD for patients with
skin involvement. When a PsA patient
fails at least one csDMARD, then
switching to a biologic DMARD is
recommended. For a patient with skin
involvement, a drug that targets inter-
leukin- 17 or IL- 12 and - 23 is preferred.
If skin involvement is not a major issue, then treatment with a TNF inhibitor is equally valid, she said.
The 2018 PsA management guideline from the American College of
Rheumatology (ACR) proposed a
strikingly different sequence, endorsing initial treatment with a TNF
inhibitor first over all other options,
including methotrexate and other
“oral small molecules” (the ACR term
for csDMARD), and also including
NSAIDs (Arthritis Rheumatol. 2019
Jan;71[ 1]: 5-32).
This schism between EULAR and
the ACR could be seen as predictable, given the different constraints
the two societies have set for themselves.
“EULAR recommendations take
into account drug costs; the ACR
guideline is supposed to be agnostic to costs,” explained Dr. Philip J.
Mease, a rheumatologist at Swedish
Medical Center in Seattle and a member of the ACR panel that wrote the
2018 PsA guideline.
In fact it was a study Dr. Mease re-
cently led and reported results from
that provided the most recent and
perhaps best assessment of a TNF in-
hibitor, compared with methotrexate,
as initial treatment for PsA, with find-
ings that suggest that, although the
advice from the two societies may
sharply differ, the viewpoints of both
groups are evidence based.
The SEAM-PsA (Study of Etanercept and Methotrexate in Subjects
With Psoriatic Arthritis) trial randomised 851 PsA patients receiving
their first treatment to methotrexate
only, the TNF inhibitor etanercept
only, or both drugs. The study’s two
coprimary outcomes, the ACR 20 and
minimal disease activity responses
after 24 weeks, showed that etanercept monotherapy produced these
responses in 61% and 36% of patients, respectively, while methotrexate monotherapy produced response
rates of 51% and 23%, respectively.
Both these differences between etanercept monotherapy and methotrexate monotherapy were statistically
significant. Combining methotrexate
with etanercept did not produce a
significant improvement over etanercept alone.
Interpreting the meaning of this finding for clinical practice “depends on
the lens you look through, ” Dr. Mease
said in an interview. “A lot of patients
respond to methotrexate, which is
good when treatment resources are
challenged. But when there is no resource challenge, the data support going straight to a TNF inhibitor.”
Prof. Laure Gossec
Dr. Philip J. Mease