Table 3.
Overview of PsA treatment algorithms: PsA symptom type*
| AAD (32) | GRAPPA (31) | EULAR (30) | ISR (34) | BSR (35) | |
|---|---|---|---|---|---|
| Peripheral | NSAIDs, corticosteroid injections, DMARDs, biologic agents | NSAIDs, corticosteroid injections, DMARDs, biologic agents | NSAIDs, corticosteroid injections, DMARDs, biologic agents | Step 1. NSAID Step 2. ≥1 DMARD, 2 months + 2 steroid injections Step 3. TNF inhibitor if ≥1 inflamed joint, pain VAS ≥40, favorable expert opinion, or radiographic evidence of progression | Step 1. NSAIDs ± local steroid injection Step 2. ≥2 DMARDs Step 3. TNF inhibitor if ≥3 swollen/tender joints or persistent or severe oligoarthritis Step 4. Second TNF inhibitor |
| Axial | – | NSAIDs, physiotherapy, biologic agents | NSAIDs, biologic agents | Step 1. NSAIDs (try ≥2 drugs, maximum doses, 3 months) Step 2. TNF inhibitor, if BASDAI ≥40, favorable expert opinion | Step 1. NSAIDs ± local steroid injection Step 2. TNF inhibitor if adverse prognostic factors† Step 3. Second TNF inhibitor |
| Enthesitis | – | NSAIDs, corticosteroid injections, physiotherapy, biologic agents | NSAIDs, corticosteroid injections, biologic agents | Step 1. NSAID, 3 months Step 2. ≥1 DMARD, + 2 local steroid injections Step 3. TNF inhibitor if favorable expert opinion, pain VAS ≥40 (0–100 mm scale), and HAQ DI ≥0.5 | – |
| Dactylitis | – | NSAIDs, corticosteroid injections, DMARDs, biologic agents | NSAIDs, corticosteroid injections, biologic agents | Step 1. NSAID, 3 months Step 2. ≥1 DMARD, + 2 local steroid injections Step 3. TNF inhibitor if favorable expert opinion, pain VAS ≥40 (0–100 mm scale), HAQ DI ≥0.5, uniformly swollen digit(s), and tenderness rating of ≥2 on 0–4 Likert scale | – |
*
PsA = psoriatic arthritis; AAD = American Academy of Dermatology; GRAPPA = Group for Research and Assessment of Psoriasis and Psoriatic Arthritis; EULAR = European League Against Rheumatism; ISR = Italian Society for Rheumatology; BSR = British Society for Rheumatology; NSAIDs = nonsteroidal antiinflammatory drugs; DMARDs = disease-modifying antirheumatic drugs; TNF = tumor necrosis factor; VAS = visual analog scale; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; HAQ = Health Assessment Questionnaire; DI = disability index.
†
Adverse prognostic factors include ≥5 swollen joints, elevated C-reactive protein, structural joint damage, or previous corticosteroid use.