Discussing the guidelines for managing psoriatic arthritis: Part 1

Discussing the guidelines for managing psoriatic arthritis: Part 1


[MUSIC PLAYING] INTERVIEWER: Hello and welcome
to this Medicine Matters podcast. Recently, the American
College of Rheumatology and the National
Psoriasis Foundation released their first
evidence-based guidelines for the management of
psoriatic arthritis. In the first of a two part
series on the new guidelines, we spoke with
Professor Dafna Gladman from the University of Toronto,
Canada, Professor Philip Mease from the University of
Washington, Seattle in the USA, and Professor Oliver FitzGerald
from University College Dublin, Ireland about how the
new guidelines were developed and the key differences
between the new ACR-NPF guidelines and the pre-existing
EULAR and GRAPPA guidelines. INTERVIEWER: Firstly,
Dafna, as a member of the core leadership
team, could you tell us about the approach
taken when developing the ACR-NPF guidelines? DAFNA: So this
guideline was based on the assessment
of the literature according to the GRADE system. There was a literature
review committee which consisted of an
independent group that was not made out of members
of the American College of Rheumatology
and, in fact, did not have rheumatologists
specifically on that panel. They reviewed the
literature and developed the analysis which was based
on a network meta-analysis. Aside from the literature
review committee, there was a core
committee, which I was a member of, that
oversaw the whole process, developed PICO questions,
and those questions were then accepted by an
expert review committee as well as a voting committee. The guideline was then submitted
to the ACR board, the Arthritis & Rheumatology Journal,
and underwent a review– a scientific review,
before it finally came out. PHILIP: Dafna, could
just share with us a bit more about
the PICO questions, so that we can understand
more about the outcomes of the guideline process. DAFNA: The P stands for
problem, patient, population. The I is intervention. The C is comparison
intervention. And the O is the outcome. So, in our case,
the P, of course, was patients with
psoriatic arthritis. The interventions
were the various drugs that we were looking at. And the comparison
was done looking at the individual
papers and it he turned to be a network
meta-analysis because we did not have any
direct comparisons between the various modalities. And, of course, the outcome was
ACR20 and the HAQ Disability Index as well as
safety indications. INTERVIEWER: Philip, you
were on the voting panel for the new guidelines, how did
this process differ from that used in the GRAPPA guidelines? PHILIP: In the case of
the ACR/NPF guideline, it was a combined effort
between the American College of Rheumatology
and the National Psoriasis Foundation in America. And both of these organizations
represent psoriatic arthritis constituencies, both
clinician investigators, clinicians in general,
as well as patients. The GRAPPA guidelines
were convened by the organization
on this group for research and
assessment of psoriasis and psoriatic arthritis. And this is an
international organization that’s comprised of key
investigators, clinicians, regulators, patient
organizations, et cetera that are interested in both psoriasis
and psoriatic arthritis. There are approximately
1,000 members of the organization at
this time representing both dermatology
and rheumatology, so it’s fairly unique
as an organization in that it crosses across
two different disciplines. INTERVIEWER: Oliver,
you were involved in the EULAR and
GRAPPA guidelines, what are your thoughts on
the processes involved? OLIVER: EULAR guidelines
were developed by the EULAR organization and
there was a committee set up– made up of predominantly
rheumatologists. There was one dermatologist
on the committee. But the focus was to look at
recommendations for treatment in psoriatic arthritis
and not psoriasis, hence the small number
of dermatologists that were involved. I guess, in that
sense, it’s more like the ACR-NPF recommendations
than the GRAPPA recommendations which, of course, included
dermatologists and included recommendations for
treatment of psoriasis. INTERVIEWER: How do you think
the clinical focus differs for each of the guidelines? PHILIP: The GRAPPA
group split itself into different committees that
reviewed the evidence for each of the key clinical domains
of psoriatic arthritis and that includes peripheral
arthritis, skin disease, nail disease, spondylitis,
enthesitis, and dactylitis. And so each committee
looked carefully at all of the treatment trials
for the various medications and then analyzed
whether or not there was demonstrated effectiveness
for each of those domains. DAFNA: The ACR-NPF is based
on active psoriatic arthritis, which includes all
of the domains, but not specifically referring
to an individual domain, although there were specific
recommendations for enthesitis, spinal disease. OLIVER: The EULAR focus
was certainly more narrow, I think, than either of
the other two guidelines. The focus was on treatment
of psoriatic arthritis. It didn’t look at other
issues that, for example, the ACR-NPF
guidelines looked at. They looked at the influence of
comorbidities, treat to target, they looked at
non-pharmacological treatments. So those were not included at
all in the EULAR guidelines, so was purely focused
on psoriatic arthritis. The ACR-NPF guidelines
didn’t break it down into the various components
of psoriatic arthritis either. INTERVIEWER: Finally,
are there differences in the treatment recommendations
between the guidelines? PHILIP: The way in
which the GRAPPA group does its work is that
they analyze the data for all classes of medications. And if the medication
appears to have an effectiveness in a
particular clinical domain of psoriatic
arthritis, then all are presented as a group
that are effective, where the ACR-NPF provides a
bit more guidance by having to choose one
class over another. So I would say then
that other than the fact that there is a bit broader
choice given to clinicians in the GRAPPA guidelines as
compared to the ACR guidelines, the outcomes were
actually fairly similar. And a key example being that
in the ACR-NPF guidelines, a fairly striking
recommendation was to recommend starting
with a TNF inhibitor before methotrexate for
the majority of patients unless there was a specific
contraindication to using a TNF inhibitor. On the GRAPPA guideline, they’re
both offered as a first option. TNF inhibitors and
methotrexate, both– either could be chosen, also,
for that matter, apremilast. OLIVER: The EULAR
recommendations, I think, at this point,
are the oldest of the three and they obviously would not
have included some agents that have become available since
2015, such as JAK inhibitors. And, largely, the
IL-17 inhibitors were only beginning to
come out around that time. So there’s limited information
available about that. One of the key findings is– that’s different is
the recommendation that for a patient with
active psoriatic arthritis that methotrexate
should be considered as a first-line treatment. And that’s certainly different
to what is recommended by the NPF-ACR guidelines. INTERVIEWER: Thank you very much
to Dafna, Philip, and Oliver for sharing their thoughts
with us on this topic. Join us next time for the second
part of this podcast where we will be discussing the
implications of the new ACR-NPF guidelines on clinical
practice, their limitations, and key research trials
in the management of psoriatic arthritis. [MUSIC PLAYING]

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