Pharmacological Treatment of Psoriatic Arthritis: A Systematic Literature Research for the 2019 Update of the EULAR Recommendations for the Management of Psoriatic Arthritis

Annals of the Rheumatic Diseases 2020;79:778-786

This SLR reviewed data on pharmacological treatment of PsA. Findings informed the 2019 EULAR taskforce when updating recommendations for PsA management. Overall, no new safety signals were reported. Encouragingly, LTEs of JAKi did not report any venous thromboembolic events or PEs. Efficacy was demonstrated for a range of bDMARD and tsDMARD therapies in various disease domains. Efficacy varied between PsA manifestations and between therapies. Observational data demonstrated efficacy when switching between treatments. EULAR recommendations on pharmacological management of PsA were updated in 2015. This SLR was undertaken to support development of the 2019 updated recommendations. Safety and efficacy literature searches were conducted using the Medline, Cochrane Library, and EMBASE databases. 5528 total search results were refined to 56 final reports for analysis through duplicate and abstract removal. Safety assessments demonstrated an increased risk of infection with bDMARD therapy, but not csDMARDs. Furthermore, TNFi-csDMARD combination therapy showed a higher risk of HZ infection compared to patients undergoing no DMARD therapy. Tofacitinib treatment demonsrated higher risks for HZ infection in JAKi treatment comparisons. MACE events were more common in PsA patients without a DMARD prescription compared to those undergoing DMARD treatment. Ixekizumab demonstrated increased rates of injection site reactions compared to controls. No venous thromboembolic events were noted in LTE studies of JAKi-treated patients. Efficacy literature demonstrated bDMARD and JAKi efficacy across all PsA domains, including in guselkumab treatment. Risankizumab only showed efficacy in arthritis and skin disease domains. The PDE4 class has demonstrated the same results overall, but radiographic outcomes are yet to be assessed. Biosimilar therapies also illustrated equivalent efficacy compared to their bio-originators. TNF and IL17-A bispecific inhibition demonstrated numerically better results in efficacy compared to adalimumab. Finally, observational studies demonstrate that switching to a second TNFi after failure of a first TNFi therapy proves effective in PsA treatment.