Psoriatic Arthritis Management (EULAR 2023)

Algorithm Steps

1. ▶

   Start

   Confirmed Psoriatic Arthritis

   Diagnosis per CASPAR criteria

   1. ●

      Action

      Overarching Principles

      Key principles for PsA management

      • Treatment goal: remission or low disease activity (MDA, DAPSA)
      • Shared decision-making with patient
      • Address ALL domains: peripheral, axial, skin, enthesitis, dactylitis
      • Consider comorbidities: CV disease, metabolic syndrome, uveitis, IBD
      • Multi-disciplinary care (rheum, derm, ophthalmology)
      1. ●

         Action

         Domain Assessment

         Identify predominant manifestations

         • Peripheral arthritis: joint count, swelling
         • Axial involvement: inflammatory back pain, limited mobility
         • Skin/nails: PASI score, BSA, nail dystrophy
         • Enthesitis: LEI, MASES scores
         • Dactylitis: digit count
         1. ◆

            Decision

            Mild Disease?

            Few joints, mild skin, no poor prognostic factors

            • Poor prognostic factors: polyarticular, structural damage, elevated CRP/ESR, dactylitis
            • Mild: oligoarticular, no erosions, mild skin involvement
            1. ●

               Action

               NSAIDs (Short-Term Only)

               For mild PsA

               • NSAIDs monotherapy ONLY for mild disease and short-term
               • NOT long-term monotherapy
               • If poor prognostic factors: start csDMARD rapidly
               • Oral GC NOT recommended (may flare psoriasis)
               1. ◆

                  Decision

                  Target Achieved at 3-6 Months?

                  Assess all domains

                  • MDA (Minimal Disease Activity): 5/7 criteria
                  • DAPSA remission (≤4) or low activity (≤14)
                  • If one domain uncontrolled: escalate based on that domain
                  1. ●

                     Action

                     Maintenance Therapy

                     Sustained remission or MDA

                     • Continue effective therapy
                     • May consider cautious dose reduction in sustained MDA
                     • Do NOT stop bDMARD (relapse risk)
                     • Continue csDMARD if using combination
                     • Monitor all domains regularly
                     1. ✓

                        Outcome

                        PsA Controlled

                        MDA or remission achieved across all domains

                  2. ●

                     Action

                     bDMARD Therapy

                     After csDMARD failure

                     • TNF inhibitor (adalimumab, etanercept, infliximab, certolizumab, golimumab)
                     • IL-17 inhibitor (secukinumab, ixekizumab, bimekizumab)
                     • IL-23 inhibitor (guselkumab, risankizumab) - especially if skin predominant
                     • Ustekinumab (IL-12/23) - less preferred unless skin-predominant
                     • Consider skin severity in selection (IL-17i, IL-23i excellent for psoriasis)
                     1. ⚠

                        Warning

                        ⚠️ Domain-Specific Drug Selection

                        Comorbidities influence choice

                        • Axial PsA: TNFi or IL-17i (like axSpA); NOT IL-23i (limited axial data)
                        • IBD: TNFi (adalimumab, infliximab); AVOID IL-17i (may worsen IBD)
                        • Uveitis: TNFi monoclonals preferred
                        • Severe skin: IL-17i, IL-23i excellent; TNFi less effective for skin
                        1. ◆

                           Decision

                           bDMARD Response at 3-6 Months?

                           Assess all domains

                           1. ●

                              Action

                              Switch bDMARD or JAK Inhibitor

                              After bDMARD failure

                              • Switch to different mechanism bDMARD
                              • JAK inhibitors: tofacitinib, upadacitinib
                              • EULAR suggests JAKi AFTER bDMARD failure (safety data ongoing)
                              • Assess CV/VTE risk before JAKi (similar to RA)
                              1. ⚠

                                 Warning

                                 Specialist Referral

                                 Refractory disease, complex comorbidities, clinical trial

            2. ●

               Action

               csDMARD Therapy (Peripheral PsA)

               First-line for peripheral arthritis

               • Methotrexate PREFERRED (15-25 mg/week with folic acid)
               • Alternative: Leflunomide, Sulfasalazine (less evidence)
               • Initiate rapidly if poor prognostic factors
               • csDMARDs NOT effective for axial disease
               • Short-term local GC injections acceptable
               1. ⚠

                  Warning

                  ⚠️ Glucocorticoid Caution

                  Not recommended in PsA

                  • Oral GC NOT recommended (may cause psoriasis flare on withdrawal)
                  • If absolutely needed: low dose, short duration
                  • Local injections (IA, peritendinous) acceptable
                  • Enthesitis: steroid injection controversial