. 2020 Sep 15;7(4):667–684. doi: 10.1007/s40744-020-00234-3

Table 2.

Treatment pathways for managing IBP and MBP in PsA

IBP (EULAR recommendations) [51]	IBP (GRAPPA, GRADE recommendations for axPsA) [93]	MBP [27, 48]
NSAIDs may be used to relieve musculoskeletal signs and symptoms (grade A recommendation) Local injections of glucocorticoids should be considered as adjunctive therapy in PsA; systemic glucocorticoids may be used with caution at the lowest effective dose (grade C recommendation) In patients with predominantly axial disease that is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNFi; when there is relevant skin involvement, IL-17 inhibitor may be preferred (grade B recommendation) In patients who fail to respond adequately to, or are intolerant of a bDMARD, switching to another bDMARD or tsDMARD should be considered, including one switch within a class (grade B recommendation) Optimal management of patients with PsA also requires nonpharmacological strategies, such as patient education and regular physical exercise, and may also require topical medication (overarching principle)	Biologic naive Strongly recommended: NSAIDs, physiotherapy, simple analgesia, TNFis Conditionally recommended: IL-17 inhibitor, SI joint CS injections, bisphosphonates, IL-12/23 inhibitor Inadequate response to bDMARDs Strongly recommended: physiotherapy, simple analgesia Conditionally recommended: NSAIDs, TNFi, IL-12/23 inhibitor, IL-17 inhibitor	Current guidance reinforces the primary emphasis of nonpharmacological measures NSAIDs/analgesics; CS can be used when necessary Physiotherapy (activity over bed rest), but rest (if acute) Behavioral approaches (mindfulness) Patient education (self-management recommendations)

IBP (EULAR recommendations) [51]

IBP (GRAPPA, GRADE recommendations for axPsA) [93]

MBP [27, 48]

NSAIDs may be used to relieve musculoskeletal signs and symptoms (grade A recommendation)

Local injections of glucocorticoids should be considered as adjunctive therapy in PsA; systemic glucocorticoids may be used with caution at the lowest effective dose (grade C recommendation)

In patients with predominantly axial disease that is active and has insufficient response to NSAIDs, therapy with a bDMARD should be considered, which according to current practice is a TNFi; when there is relevant skin involvement, IL-17 inhibitor may be preferred (grade B recommendation)

In patients who fail to respond adequately to, or are intolerant of a bDMARD, switching to another bDMARD or tsDMARD should be considered, including one switch within a class (grade B recommendation)

Optimal management of patients with PsA also requires nonpharmacological strategies, such as patient education and regular physical exercise, and may also require topical medication (overarching principle)

Biologic naive

Strongly recommended: NSAIDs, physiotherapy, simple analgesia, TNFis

Conditionally recommended: IL-17 inhibitor, SI joint CS injections, bisphosphonates, IL-12/23 inhibitor

Inadequate response to bDMARDs

Strongly recommended: physiotherapy, simple analgesia

Conditionally recommended: NSAIDs, TNFi, IL-12/23 inhibitor, IL-17 inhibitor

Current guidance reinforces the primary emphasis of nonpharmacological measures

NSAIDs/analgesics; CS can be used when necessary

Physiotherapy (activity over bed rest), but rest (if acute)

Behavioral approaches (mindfulness)

Patient education (self-management recommendations)

axPsA axial psoriatic arthritis, bDMARD biologic disease-modifying antirheumatic drug, CS corticosteroids, EULAR European League Against Rheumatism, GRADE Grading of Recommendations, Assessment, Development and Evaluation, GRAPPA Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, IBP inflammatory back pain, IL interleukin, MBP mechanical back pain, NSAID nonsteroidal anti-inflammatory drug, PsA psoriatic arthritis, SI sacroiliac, TNFi tumor necrosis factor inhibitor