Table 3.

Recommendations for treatment of patients with active psoriatic arthritis despite treatment with a TNFi biologic, as monotherapy or in combination with MTX (PICOs 26–35; 70–75)^*

	Level of evidence (evidence [refs.] reviewed)†
In adult patients with active PsA despite treatment with a TNFi biologic monotherapy,
1. Switch to a different TNFi biologic over switching to an IL-17i biologic (PICO 28)	Low (72, 73, 90–93, 95)
Conditional recommendation based on low-quality evidence; may consider an IL-17i if the patient had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse event or severe psoriasis.‡
2. Switch to a different TNFi biologic over switching to an IL-12/23i biologic (PICO 27)	Low (72, 73, 99, 100)
Conditional recommendation based on low-quality evidence; may consider an IL-12/23i if the patient had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse effect or prefers less frequent drug administration.
3. Switch to a different TNFi biologic over switching to abatacept (PICO 70)	Low (72, 73, 103, 104)
Conditional recommendation based on low-quality evidence; may consider abatacept if the patient had a primary TNFi biologic efficacy failure or TNFi biologic-associated serious adverse effect.
4. Switch to a different TNFi biologic over switching to tofacitinib (PICO 73)	Low (62–66, 72–78, 105)
Conditional recommendation based on low-quality evidence; may consider tofacitinib if the patient prefers an oral therapy or had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse effect.
5. Switch to a different TNFi biologic (with or without MTX) over adding MTX to the same TNFi biologic monotherapy (PICO 26 and 26A)	Very low
Conditional recommendation based on very-low-quality evidence; may consider adding MTX when patients have demonstrated partial response to the current TNFi biologic therapy, especially if the TNFi biologic is a monoclonal antibody.
6. Switch to an IL-17i biologic over switching to an IL-12/23i biologic (PICO 29)	Low (90–93, 95, 99, 100)
Conditional recommendation based on low-quality evidence; may consider an IL-12/23i if the patient has IBD or if the patient prefers less frequent drug administration.
7. Switch to an IL-17i biologic over abatacept (PICO 72)	Low (90–93, 95, 103, 104, 112)
Conditional recommendation based on low-quality evidence; may consider abatacept if the patient prefers IV dosing or in patients with recurrent or serious infections.
8. Switch to an IL-17i biologic over tofacitinib (PICO 75)	Low (90–93, 105)
Conditional recommendation based on low-quality evidence; may consider tofacitinib if the patient prefers an oral therapy or in patients with concomitant IBD or a history of recurrent Candida infections.
9. Switch to an IL-12/23i biologic over abatacept (PICO 71)	Low (99, 100, 103, 104)
Conditional recommendation based on of low-quality evidence; may consider abatacept if the patient prefers IV dosing or in patients with recurrent or serious infections.
10. Switch to an IL-12/23i biologic over tofacitinib (PICO 74)	Low (98–100, 105)
Conditional recommendation based on low-quality evidence; may consider tofacitinib if the patient prefers an oral therapy.
11. Switch to a different TNFi biologic monotherapy over switching to a different TNFi biologic and MTX combination therapy (PICO 30)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to a TNFi biologic and MTX combination therapy if the current TNFi biologic is infliximab.
12. Switch to an IL-17i biologic monotherapy over switching to an IL-17i biologic and MTX combination therapy (PICO 32)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to an IL-17i biologic and MTX combination therapy in patients with concomitant uveitis, as uveitis may respond to MTX therapy.
13. Switch to an IL-12/23i biologic monotherapy over switching to an IL-12/23i biologic and MTX combination therapy (PICO 31)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to an IL-12/23i biologic and MTX combination therapy if the patient has severe psoriasis.
In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy,
14. Switch to a different TNFi biologic + MTX over switching to a different TNFi biologic monotherapy (PICO 33)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to a different TNFi biologic monotherapy if the patient has demonstrated MTX-associated adverse events, prefers to receive fewer medications, or perceives MTX as a burden.
15. Switch to an IL-17i biologic monotherapy over an IL-17i biologic and MTX combination therapy (PICO 35)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to an IL-17i biologic and MTX combination therapy if the patient had had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL-17i biologic was discussed as potentially beneficial to allow the new therapy time to work.
16. Switch to IL-12/23i biologic monotherapy over IL-12/23i biologic and MTX combination therapy (PICO 34)	Very low
Conditional recommendation based on very-low-quality evidence; may consider switching to an IL-12/23i biologic and MTX combination therapy if the patient had had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL-12/23i biologic was discussed as potentially beneficial to allow the new therapy time to work.

^*Active psoriatic arthritis (PsA) is defined as disease causing symptoms at an unacceptably bothersome level as reported by the patient, and judged by the examining clinician to be due to PsA based on ≥1 of the following: swollen joints, tender joints, dactylitis, enthesitis, axial disease, active skin and/or nail involvement, and extraarticular inflammatory manifestations such as uveitis or inflammatory bowel disease (IBD). TNFi = tumor necrosis factor inhibitor; MTX = methotrexate; IL-17i = interleukin-17 inhibitor; IV = intravenous.

^†When there were no published studies, we relied on the clinical experience of the panelists, which was designated very-low-quality evidence.

^‡Because there are currently no widely agreed-upon definitions of disease severity, psoriasis severity should be established by the health care provider and patient on a case-by-case basis. In clinical trials, severe psoriasis has been defined as a Psoriasis Area and Severity Index (PASI) score (25) of ≥12 and a body surface area score of ≥10. In clinical practice, however, the PASI tool is not standardly utilized given its cumbersome nature. In 2007, the National Psoriasis Foundation published an expert consensus statement, which defined moderate-to-severe disease as a body surface area of ≥5% (68). In cases in which the involvement is in critical areas, such as the face, hands or feet, nails, intertriginous areas, scalp, or where the burden of the disease causes significant disability or impairment of physical or mental functioning, the disease can be severe despite the lower amount of surface area of skin involved. The need to factor in the unique circumstances of the individual patient is of critical importance, but this threshold provides some guidance in the care of patients.