Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Opinion
  • Published:

Management of psoriatic arthritis in 2016: a comparison of EULAR and GRAPPA recommendations

Nature Reviews Rheumatology volume 12, pages 743–750 (2016)Cite this article

Subjects

Abstract

Psoriatic arthritis (PsA) is a heterogeneous, potentially severe disease. Many therapeutic agents are now available for PsA, but treatment decisions are not always straightforward. To assist in this decision making, two sets of recommendations for the management of PsA were published in 2016 by international organizations — the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). In both sets of recommendations, the heterogeneity of PsA is recognized and the place of various drugs in the therapeutic armamentarium is discussed. Such agents include conventional DMARDs, such as methotrexate, and targeted therapies including biologic agents, such as ustekinumab, secukinumab and TNF inhibitors, or the targeted synthetic drug apremilast. The proposed sequential use of these drugs, as well as some other aspects of PsA management, differ between the two sets of recommendations. This disparity is partly the result of a difference in the evaluation process; the focus of EULAR was primarily rheumatological, whereas that of GRAPPA was balanced between the rheumatological and dermatological aspects of disease. In this Perspectives article, we address the similarities and differences between these two sets of recommendations and the implications for patient management.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Simplified EULAR and GRAPPA treatment algorithms for predominant peripheral psoriatic arthritis5,6.
Figure 2: Simplified EULAR and GRAPPA treatment algorithms for predominant entheseal psoriatic arthritis5,6.
Figure 3: Simplified EULAR and GRAPPA treatment algorithms for predominant axial psoriatic arthritis5,6.

Similar content being viewed by others

References

  1. Chandran, V. & Raychaudhuri, S. P. Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis. J. Autoimmun. 34, J314–J321 (2010).

    Article  CAS  PubMed  Google Scholar 

  2. Boehncke, W. H. & Menter, A. Burden of disease: psoriasis and psoriatic arthritis. Am. J. Clin. Dermatol. 14, 377–388 (2013).

    Article  PubMed  Google Scholar 

  3. Frleta, M., Siebert, S. & McInnes, I. B. The interleukin-17 pathway in psoriasis and psoriatic arthritis: disease pathogenesis and possibilities of treatment. Curr. Rheumatol. Rep. http://dx.doi.org/10.1007/s11926-014-0414-y (2014).

  4. Krueger, G. et al. The impact of psoriasis on quality of life: results of a 1998 national psoriasis foundation patient-membership survey. Arch. Dermatol. 137, 280–284 (2001).

    CAS  PubMed  Google Scholar 

  5. Gossec, L. et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann. Rheum. Dis. 75, 499–510 (2016).

    Article  CAS  PubMed  Google Scholar 

  6. Coates, L. C. et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis: treatment recommendations for psoriatic arthritis 2015. Arthritis Rheumatol. 68, 1060–1071 (2016).

    PubMed  Google Scholar 

  7. Gossec, L. et al. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann. Rheum. Dis. 71, 4–12 (2012).

    Article  CAS  PubMed  Google Scholar 

  8. Ritchlin, C. T. et al. Treatment recommendations for psoriatic arthritis. Ann. Rheum. Dis. 68, 1387–1394 (2009).

    Article  CAS  PubMed  Google Scholar 

  9. van der Heijde, D. et al. 2014 update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann. Rheum. Dis. 74, 8–13 (2015).

    Article  PubMed  Google Scholar 

  10. Coates, L. et al. New GRAPPA and EULAR recommendations for the management of psoriatic arthritis: process and challenges faced. Rheumatology (Oxford) (In press).

  11. de Wit, M. P. et al. European League Against Rheumatism recommendations for the inclusion of patient representatives in scientific projects. Ann. Rheum. Dis. 70, 722–726 (2011).

    Article  CAS  PubMed  Google Scholar 

  12. Cheung, P. P. et al. Recommendations for the involvement of Patient Research Partners (PRP) in OMERACT working groups. A report from the OMERACT 2014 working group on PRP. J. Rheumatol. 43, 187–193 (2016).

    Article  PubMed  Google Scholar 

  13. Smolen, J. S., van der Heijde, D., Machold, K. P., Aletaha, D. & Landewé, R. Proposal for a new nomenclature of disease-modifying antirheumatic drugs. Ann. Rheum. Dis. 73, 3–5 (2014).

    Article  CAS  PubMed  Google Scholar 

  14. Shaw, A. T. & Gravallese, E. M. Mediators of inflammation and bone remodeling in rheumatic disease. Semin. Cell Dev. Biol. 49, 2–10 (2016).

    Article  CAS  PubMed  Google Scholar 

  15. Schünemann, H. J. et al. GRADE Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical practice and public health. J. Clin. Epidemiol. 76, 89–98 (2016).

    Article  PubMed  Google Scholar 

  16. Ash, Z. et al. A systematic literature review of drug therapies for the treatment of psoriatic arthritis: current evidence and meta-analysis informing the EULAR recommendations for the management of psoriatic arthritis. Ann. Rheum. Dis. 71, 319–326 (2012).

    Article  CAS  PubMed  Google Scholar 

  17. Eder, L. et al. Predictors of response to intra-articular steroid injection in psoriatic arthritis. Rheumatology (Oxford) 49, 1367–1373 (2010).

    Article  Google Scholar 

  18. Braun, J. et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann. Rheum. Dis. 70, 896–904 (2011).

    Article  CAS  PubMed  Google Scholar 

  19. Bond, S. J., Farewell, V. T., Schentag, C. T. & Gladman, D. D. Predictors for radiological damage in psoriatic arthritis: results from a single centre. Ann. Rheum. Dis. 66, 370–376 (2007).

    Article  PubMed  Google Scholar 

  20. McHugh, N. J., Balachrishnan, C. & Jones, S. M. Progression of peripheral joint disease in psoriatic arthritis: a 5-yr prospective study. Rheumatology (Oxford) 42, 778–783 (2003).

    Article  CAS  Google Scholar 

  21. Gladman, D. D. et al. Risk factors for radiographic progression in psoriatic arthritis: subanalysis of the randomized controlled trial ADEPT. Arthritis Res. Ther. 12, R113 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Cresswell, L., Chandran, V., Farewell, V. T. & Gladman, D. D. Inflammation in an individual joint predicts damage to that joint in psoriatic arthritis. Ann. Rheum. Dis. 70, 305–308 (2011).

    Article  PubMed  Google Scholar 

  23. Smolen, J. S. et al. Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force. Ann. Rheum. Dis. 73, 6–16 (2014).

    Article  PubMed  Google Scholar 

  24. Coates, L. C. et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet 386, 2489–2498 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  25. Acosta Felquer, M. L. et al. Remission criteria and activity indices in psoriatic arthritis. Clin. Rheumatol. 33, 1323–1330 (2014).

    Article  CAS  PubMed  Google Scholar 

  26. Van den Bosch, F., Kavanaugh, A., Kron, M., Kupper, H. & Mease, P. J. Clinical remission in patients with active psoriatic arthritis treated with adalimumab and correlations in joint and skin manifestations. J. Rheumatol. 42, 952–959 (2015).

    Article  CAS  PubMed  Google Scholar 

  27. Cantini, F., Niccoli, L., Cassarè, E., Kaloudi, O. & Nannini, C. Sustained maintenance of clinical remission after adalimumab dose reduction in patients with early psoriatic arthritis: a long-term follow-up study. Biologics 6, 201–206 (2012).

    CAS  PubMed  PubMed Central  Google Scholar 

  28. Coates, L. C. & Helliwell, P. S. Validation of minimal disease activity criteria for psoriatic arthritis using interventional trial data. Arthritis Care Res. 62, 965–969 (2010).

    Article  Google Scholar 

  29. Coates, L. C., Cook, R., Lee, K.-A., Chandran, V. & Gladman, D. D. Frequency, predictors, and prognosis of sustained minimal disease activity in an observational psoriatic arthritis cohort. Arthritis Care Res. 62, 970–976 (2010).

    Article  Google Scholar 

  30. Coates, L. C., Fransen, J. & Helliwell, P. S. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann. Rheum. Dis. 69, 48–53 (2010).

    Article  CAS  PubMed  Google Scholar 

  31. Haddad, A. et al. Minimal disease activity and anti-tumor necrosis factor therapy in psoriatic arthritis. Arthritis Care Res. 67, 842–847 (2015).

    Article  CAS  Google Scholar 

  32. Schoels, M., Aletaha, D., Alasti, F. & Smolen, J. S. Disease activity in psoriatic arthritis (PsA): defining remission and treatment success using the DAPSA score. Ann. Rheum. Dis. 75, 811–818 (2016).

    Article  PubMed  Google Scholar 

  33. Salaffi, F., Ciapetti, A., Carotti, M., Gasparini, S. & Gutierrez, M. Disease activity in psoriatic arthritis: comparison of the discriminative capacity and construct validity of six composite indices in a real world. Biomed. Res. Int. 2014, 528105 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Husic, R. et al. Disparity between ultrasound and clinical findings in psoriatic arthritis. Ann. Rheum. Dis. 73, 1529–1536 (2014).

    Article  PubMed  Google Scholar 

  35. Coates, L. C. & Helliwell, P. S. Defining low disease activity states in psoriatic arthritis using novel composite disease instruments. J. Rheumatol. 43, 371–375 (2016).

    Article  CAS  PubMed  Google Scholar 

  36. Coates, L. C., Kavanaugh, A., Ritchlin, C. T. & GRAPPA Treatment Guideline Committee. Systematic review of treatments for psoriatic arthritis: 2014 update for the GRAPPA. J. Rheumatol. 41, 2273–2276 (2014).

    Article  PubMed  Google Scholar 

  37. Kingsley, G. H. et al. A randomized placebo-controlled trial of methotrexate in psoriatic arthritis. Rheumatology (Oxford) 51, 1368–1377 (2012).

    Article  CAS  Google Scholar 

  38. Pincus, T., Bergman, M. J. & Yazici, Y. Limitations of clinical trials in chronic diseases: is the efficacy of methotrexate (MTX) underestimated in polyarticular psoriatic arthritis on the basis of limitations of clinical trials more than on limitations of MTX, as was seen in rheumatoid arthritis? Clin. Exp. Rheumatol. 33 (Suppl. 93), S82–S93 (2015).

    PubMed  Google Scholar 

  39. Lie, E. et al. Effectiveness and retention rates of methotrexate in psoriatic arthritis in comparison with methotrexate-treated patients with rheumatoid arthritis. Ann. Rheum. Dis. 69, 671–676 (2010).

    Article  CAS  PubMed  Google Scholar 

  40. Coates, L. C. & Helliwell, P. S. Methotrexate efficacy in the Tight Control in Psoriatic Arthritis study. J. Rheumatol. 43, 356–361 (2016).

    Article  CAS  PubMed  Google Scholar 

  41. Acosta Felquer, M. L. et al. Drug therapies for peripheral joint disease in psoriatic arthritis: a systematic review. J. Rheumatol. 41, 2277–2285 (2014).

    Article  PubMed  Google Scholar 

  42. Baranauskaite, A. et al. Infliximab plus methotrexate is superior to methotrexate alone in the treatment of psoriatic arthritis in methotrexate-naive patients: the RESPOND study. Ann. Rheum. Dis. 71, 541–548 (2012).

    Article  CAS  PubMed  Google Scholar 

  43. Ramiro, S. et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann. Rheum. Dis. 75, 490–498 (2016).

    Article  CAS  PubMed  Google Scholar 

  44. McInnes, I. B. et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet 382, 780–789 (2013).

    Article  CAS  PubMed  Google Scholar 

  45. Ritchlin, C. et al. Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial. Ann. Rheum. Dis. 73, 990–999 (2014).

    Article  CAS  PubMed  Google Scholar 

  46. Mease, P. J. et al. Secukinumab inhibition of interleukin-17A in patients with psoriatic arthritis. N. Engl. J. Med. 373, 1329–1339 (2015).

    Article  CAS  PubMed  Google Scholar 

  47. McInnes, I. B. et al. Secukinumab, a human anti-interleukin-17A monoclonal antibody, in patients with psoriatic arthritis (FUTURE 2): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 386, 1137–1146 (2015).

    Article  CAS  PubMed  Google Scholar 

  48. Griffiths, C. E. et al. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials. Lancet. 386, 541–551 (2015).

    Article  CAS  PubMed  Google Scholar 

  49. Langley, R. G. et al. Secukinumab in plaque psoriasis — results of two phase 3 trials. N. Engl. J. Med. 371, 326–338 (2014).

    Article  PubMed  Google Scholar 

  50. Schett, G. et al. Oral apremilast in the treatment of active psoriatic arthritis: results of a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 64, 3156–3167 (2012).

    Article  CAS  PubMed  Google Scholar 

  51. Kavanaugh, A. et al. Treatment of psoriatic arthritis in a phase 3 randomised, placebo-controlled trial with apremilast, an oral phosphodiesterase 4 inhibitor. Ann. Rheum. Dis. 73, 1020–1026 (2014).

    Article  CAS  PubMed  Google Scholar 

  52. Edwards, C. J. et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with psoriatic arthritis and current skin involvement: a phase III, randomised, controlled trial (PALACE 3). Ann. Rheum. Dis. 75, 1065–1073 (2016).

    Article  CAS  PubMed  Google Scholar 

  53. Wells, A. et al. SAT0382 Palace 4, a phase 3, randomized, controlled trial of apremilast, an oral phosphodiesterase 4 inhibitor, for treatment of psoriatic arthritis: long-term (52-week) improvements in physical function. Ann. Rheum. Dis. 73 (Suppl. 2), 732 (2014).

    Google Scholar 

  54. Celgene. Celgene Reports Fourth Quarter and Full Year 2015 Operating and Financial Results. Celgene http://ir.celgene.com/releasedetail.cfm?ReleaseID=952157 (2016).

  55. U.S. Food & Drug Administration. Information on biosimilars. FDA http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/Biosimilars/default.htm (2016).

  56. Dörner, T. & Kay, J. Biosimilars in rheumatology: current perspectives and lessons learnt. Nat. Rev. Rheumatol. 11, 713–724 (2015).

    Article  PubMed  Google Scholar 

  57. Putrik, P. et al. Inequities in access to biologic and synthetic DMARDs across 46 European countries. Ann. Rheum. Dis. 73, 198–206 (2014).

    Article  CAS  PubMed  Google Scholar 

  58. Ogdie, A. et al. Comprehensive treatment of psoriatic arthritis: managing comorbidities and extra-articular manifestations. J. Rheumatol. 41, 2315–2322 (2014).

    Article  CAS  PubMed  Google Scholar 

  59. World Health Organization. WHO handbook for guideline development [online], (2012).

Download references

Author information

Authors and Affiliations

  1. Laure Gossec is at the Sorbonne Universités, Université Pierre and Marie Curie – Paris 6, 4 Place Jussieu 75005, Paris, France; and at the Service de Rhumatologie, L'Assistance Publique – Hôpitaux de Paris, Pitié Salpêtrière Hôpital, 47–83 Boulevard de l'Hôpital, 75013, Paris, France.,

    Laure Gossec

  2. and at the Service de Rhumatologie, L'Assistance Publique – Hôpitaux de Paris, Pitié Salpêtrière Hôpital, 47–83 Boulevard de l'Hôpital, 75013, Paris, France.,

    Laure Gossec

  3. Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds; and at the Leeds Musculoskeletal Biomedical Research Unit, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,

    Laura C. Coates

  4. and at the Leeds Musculoskeletal Biomedical Research Unit, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,

    Laura C. Coates

  5. Department of Medical Humanities, Vrije Universiteit Medical Centre, POBox 7057, Amsterdam, 1007 MB, Netherlands

    Maarten de Wit

  6. Division of Rheumatology, Department of Medicine, Allergy & Immunology, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, 92093–0656, California, USA

    Arthur Kavanaugh

  7. Department of Rheumatology, Leiden University Medical Centre, POBox 9600, 2300 RC, Leiden, Netherlands

    Sofia Ramiro & Désirée van der Heijde

  8. Rheumatology Clinical Research Division, Swedish Medical Center, 601 Broadway, Suite 600, Seattle, 98102, Washington, USA

    Philip J. Mease

  9. Division of Allergy, Department of Medicine, Immunology and Rheumatology, University of Rochester Medical Center, 601 Elmwood Avenue, BOX 695, Rochester, 14642, New York, USA

    Christopher T. Ritchlin

  10. Division of Rheumatology, Department of Medicine 3, Austria; and at the 2nd Department of Medicine, Medical University of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Hietzing Hospital, Wolkersbergenstraße 1, 1130 Vienna, Austria.,

    Josef S. Smolen

  11. and at the 2nd Department of Medicine, Hietzing Hospital, Wolkersbergenstraße 1, 1130 Vienna, Austria.,

    Josef S. Smolen

Authors
  1. Laure Gossec
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Laura C. Coates
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maarten de Wit
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Arthur Kavanaugh
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sofia Ramiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Philip J. Mease
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Christopher T. Ritchlin
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Désirée van der Heijde
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Josef S. Smolen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

L.G., L.C.C., A.F.K., S.R., P.J.M., C.T.R., D.v.d.H. and J.S.S. researched data for the article. All authors made a substantial contribution to the discussion of content, wrote the article, and reviewed or edited the manuscript before submission. L.G. and L.C.C. contributed equally.

Corresponding author

Correspondence to Laure Gossec.

Ethics declarations

Competing interests

The authors declare a potential conflict of interest having received grant support and/or honoraria for consultations and/or for presentations as indicated: L.G. Abbvie, BMS, Celgene, Chugai, Janssen, MSD, Novartis, Pfizer, Roche, UCB. L.C.C. Abbvie, Amgen, Boehringer Ingelheim, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, UCB. M.d.W. BMS, Celgene, Novartis, Roche. A.K. AbbVie, Amgen, Celgene, Janssen, Novartis, UCB. S.R. no competing interests. P.M. Abbvie, Amgen, Celgene, BMS, Boehringer Ingelheim, Janssen, Lilly, Merck, Novartis, Pfizer, UCB. C.R. Abbvie, Amgen, Boehringer Ingelheim, Janssen, Lilly, Novartis, Pfizer, UCB. D.v.d.H. AbbVie, Amgen, Astellas, AstraZeneca, Augurex, BMS, Boehringer Ingelheim, Celgene, Centocor, Chugai, Covagen, Daiichi, Eli-Lilly, Galapagos, GSK, Janssen Biologics, Merck, Novartis, Novo-Nordisk, Otsuka, Pfizer, Roche, Sanofi-Aventis, UCB, Vertex. Director of Imaging Rheumatology bv. J.S.S. Abbvie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Glaxo, ILTOO, Janssen, Merck-Serono, MSD, Novartis-Sandoz, Pfizer, Roche-Chugai, Samsung, UCB.

Related links

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gossec, L., Coates, L., de Wit, M. et al. Management of psoriatic arthritis in 2016: a comparison of EULAR and GRAPPA recommendations. Nat Rev Rheumatol 12, 743–750 (2016). https://doi.org/10.1038/nrrheum.2016.183

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrrheum.2016.183

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing