Photo Credit: Jacques Hugo

A panel of experts from the UK issued enhanced, evidence-based best-practice guidance to help clinicians assess and manage patients with PsA.

An expert consensus panel in the United Kingdom has issued evidence-based best practice recommendations to help physicians diagnose, assess, and manage psoriatic arthritis (PsA).

Existing guidelines “give comprehensive guidance on the diagnosis and pharmacological management of PsA,” Laura C. Coates, MBChB, MRCP, PhD, and colleagues wrote in Rheumatology. To bridge gaps in care, experts in various specialties undertook an industry-sponsored project to develop enhanced evidence- and consensus-based recommendations. 

“This guidance applies to patient care in the United States and is not for rheumatologists only but for all physicians,” says Zhanna Mikulik, MD, who was not involved in developing the document.

Using a modified Delphi methodology, the authors reviewed standard medical databases for studies on four consensus themes: PsA diagnosis, disease assessment, comorbidities, and management. The researchers used 174 studies that met their selection criteria to develop recommendations for clinical practice.

Diagnosis

• Anyone with psoriasis (PsO) or a family history of PsO may develop PsA.
• Axial disease may be present in a high proportion of patients with PsA.
• Questionnaire-based screening tools have moderate accuracy for screening for PsA, but cost-effectiveness and the number needed to screen have not been established.
• Patient-completed screening tools may be useful in detecting PsA in patients with PsO, but these may have limited specificity.
• Screening tools are not diagnostic tools and cannot prove or exclude a diagnosis of PsA, but they may help determine the need for referral to rheumatology.
• Imaging alone cannot diagnose or exclude PsA and must be assessed in context.

Assessment

• Holistic patient assessment should include disease activity, functional impairment, and broader impact from the patient’s perspective.
• Routinely use patient-reported outcome measures.
• If reviewing quality of care, consider including patient-reported experience measures.
• At minimum, clinicians caring for someone with PsA should assess joints, enthesitis, spine, skin, and comorbidities.
• Imaging may be used as an adjunct to support decisions to change or escalate therapy.

Comorbidities

• Given the limited data on the management of many common PsA comorbidities, including hyperlipidemia, hypertension, and diabetes, use appropriate, condition-specific recommendations.
• Comorbidity treatment in PsA should involve a multidisciplinary approach that includes primary care and appropriate specialties.
• For patients with PsA who are overweight or obese, consider a proactive approach to weight loss that follows national guidelines and local services.
• In people with PsA and depression, consider proactive management, following national guidelines and local services.
• Before initiating therapy, consider that some comorbidities, including depression and fatty liver disease, may affect pharmacological PsA management.

Management

• Refer to national and international treatment recommendations for guidance on pharmacological PsA management.
• Strictly minimize corticosteroid use in patients with PsA and proactively consider alternative therapies.
• Exercise caution when tapering steroids in people with PsA due to the significant risk of PsO flare associated with steroid withdrawal, and inform patients of this risk.
• Smoking cessation support is highly recommended, in line with current national guidelines.
• Advise patients with PsA to engage in muscle strengthening and general aerobic exercise, taking into account current disease activity, comorbidities, and patient preferences.
• Treat active inflammation promptly to improve long-term outcomes, with referral and management by an early inflammatory arthritis clinic.
• Use a treat-to-target management strategy in line with national and international recommendations.
• In target selection, consider all PsA disease manifestations. Minimal disease activity is the evidence-based multi-domain target when treating PsA.
• When discussing treatment options, use shared decision-making and align patient and physician goals.
• Key specialties (dermatology, gastroenterology, ophthalmology) should collaborate to optimize outcomes for patients with PsA, and multidisciplinary clinics are recommended.

“I like the authors’ idea of multidisciplinary clinics. These clinics should include primary care physicians who manage patients and screen for comorbidities, which can affect the patients and the treatment,” Dr. Mikulik says.

She disagrees, though, with the statement that physicians can rely on patient accounts of relevant signs and symptoms of comorbidities rather than formal assessments.

“Patients can be asymptomatic for comorbidities such as metabolic syndrome, diabetes, and nonalcoholic fatty liver disease,” she says. “Diagnosing PsA early is important so treatment can start before the patient has joint damage, but it’s often delayed. Screening tests are needed.”