Consensus Guidelines for Psoriasis-Related Disease

From Medscape Rheumatology > Viewpoints

Kevin Deane, MD

Review data Treatment Recommendations for Psoriatic Arthritis
Ritchlin CT, Kavanaugh A, Gladman DD, et al; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
Ann Rheum Dis. 2009;68:1387-1394

Study Summary
Treating the "heartbreak"* and "joint-ache" of psoriasis has become easier with the introduction of effective disease-modifying drugs such as methotrexate and leflunomide, and especially with the introduction of biological therapy such as anti-tumor necrosis factor (TNF)-alpha agents. However, given the wide range of literature on the diagnosis and treatment of psoriatic-associated conditions, it may be difficult for an individual clinician to know which treatments are best studied. These study authors reviewed the literature on the treatment of psoriatic conditions and made recommendations regarding the use of available therapies.

Members of the multinational Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) (including rheumatologists, dermatologists, and patients) reviewed the psoriasis literature and graded it according to criteria established by the Agency for Health Care Policy Research (AHCPR), with scores ranging from 1a and 1b (meta-analysis of randomized controlled trials [RCTs]) through 4 (expert committee/clinical experience). Next, on the basis of this literature review, subcommittees of GRAPPA members graded treatment recommendations regarding the 6 conditions related to psoriasis: peripheral arthritis, nail disease, spinal disease, skin disease, dactylitis, and enthesitis.

Grade A recommendations were based on evel 1a-1b evidence, with grade B recommendations based on 2a-2b evidence (1 or more controlled trials, no randomization, or other well-designed study). Finally, diagnostic and treatment recommendations were formed and sent in survey form to all members of GRAPPA, 70 of whom responded, and the level of agreement with the treatment recommendations was calculated.

Treatment options scored by GRAPPA as grade A for moderate-severe peripheral arthritis (with approximately 90% agreement) included: sulfasalazine, leflunomide, and TNF-alpha inhibitors. Of note, methotrexate was scored as grade B.
For psoriatic skin disease, phototherapy, methotrexate, TNF-alpha inhibitors, efalizumab, cyclosporine, leflunomide, and sulfasalazine were graded as A (approximately 69% agreement).
For spinal disease, nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, analgesia, sacroiliac joint injections, and TNF inhibitors were all grade A (approximately 86% agreement).
For enthesitis, TNF-alpha antagonists were graded A, with others, including NSAIDs and oral disease-modifying antirheumatic drugs, given a grade D (approximately 88% agreement).

Viewpoint
Consensus statements such as the one discussed here allow for an individual clinician to quickly review the available data and make diagnostic or treatment decisions based on expert review of the literature. These reviews are dependent on many factors, including: (1) the quality of literature review and expert panel evaluation; (2) the availability of good RCTs; and (3) timely updates. However, for a disease such as psoriasis, in which clinical manifestations are protean, and multiple types of physicians may care for patients, consensus statements such as this may be the best way to summarize large amounts of data for clinically useful recommendations.

*The term "heartbreak of psoriasis" originated with a 1960s advertising campaign for the coal-tar treatment Tegrin.

Abstract