Figure 4.

Recommendations for the treatment of patients with active psoriatic arthritis (PsA) despite treatment with oral small molecules (OSMs). All recommendations are conditional based on low- to very-low-quality evidence. A conditional recommendation means that the panel believed the desirable effects of following the recommendation probably outweigh the undesirable effects, so the course of action would apply to the majority of the patients, but some may not want to follow the recommendation. Because of this, conditional recommendations are preference sensitive and always warrant a shared decision-making approach. Due to the complexity of management of active PsA, not all clinical situations and choices could be depicted in this flow chart, and therefore we show only the key recommendations. For a complete list of recommendations, please refer to the Results section of the text. For the level of evidence supporting each recommendation, see Table 2 and the related section in the Results. TNFi = tumor necrosis factor inhibitor; IL-17i = interleukin-17 inhibitor; MTX = methotrexate.