At the end of 2018, the National Psoriasis Foundation, in partnership with the American College of Rheumatology (ACR), released a collaborative publication about treating psoriatic arthritis.
If this sounds like something that will soon be relegated to some medical journal’s archive, you’re mistaken. The American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis has the potential to change the treatment of psoriatic arthritis (PsA).
The guideline is the culmination of two years of collaboration between NPF and ACR. The 32 rheumatologists and dermatologists who worked on the paper, and who are the co-authors of articles published in NPF’s Journal of Psoriasis and Psoriatic Arthritis and in Arthritis & Rheumatology, represent a who’s who of research and clinical care in the U.S.
If you have PsA, or if you have psoriasis and you’re concerned about developing PsA, what does this mean for you?
“Plain and simple, the guideline will change the standard of care,” says Randy Beranek, president and CEO of NPF. “The significance of the guideline is that it now changes the existing treatment practices. For the first time, doctors who care for people with PsA not only have a guide to all current treatments, they also have the evidence-backed recommendation to use biologics as a front-line treatment. This should lead to better long-term health outcomes for our community.”
“Health insurers have long emphasized the importance of a standard set of treatment guidelines,” says Leah McCormick Howard, J.D., chief operating officer of NPF. “They want to see evidence-based guidelines that will influence clinical practice. Guidelines are a critical part of what insurers look at when they make decisions about the effectiveness, safety and cost of a therapy. The more precise such guidelines are and the more widely they’re used, the more they will impact health insurers’ decisions.”
New Emphasis on Biologics
Philip Mease, M.D., one of the co-authors of the Journal of Psoriasis and Psoriatic Arthritis/Arthritis & Rheumatology article, is a clinical professor at the University of Washington School of Medicine and director of the Rheumatology Clinical Research Division at Swedish Medical Center in Seattle, Washington. Mease’s involvement in PsA research and patient care dates back to the early ’90s. In fact, he was the lead author or co-author of most of the papers from which the guideline was derived.
Mease cites two firsts for this paper:
- A professional body has acknowledged that a biologic treatment is, in general, better than a systemic. The ACR/NPF PsA Guideline calls for tumor necrosis factor inhibitor biologics to be used as the front-line treatment for PsA.
- The inclusion of evidence that patients can benefit from what Mease calls “self-management,” for instance, diet, exercise and physical therapy. Although 90 percent of the recommendations in the ACR/NPF PsA guideline are labeled “conditional,” the rest are considered “strong,” including the recommendation to avoid or stop smoking.
Jasvinder Singh, M.D., MPH, professor of medicine and epidemiology at the University of Alabama at Birmingham was the principal investigator and led the project from beginning to end.
“The guidelines should have an impact on care of the patients. The significance is obvious,” he says. “Patients can access these therapies without first trying systemics.”
Mease cautions against expecting an immediate change. “Guidelines dissemination takes time, presentations and discussions to osmose their way into the thinking of care providers and payors,” he says. “I don’t expect an overnight switch, but I do anticipate a gradual sea change of the usual paradigm of treatment.”
He also says the treatment guideline will have the unintended effect of raising awareness, thanks to NPF. “When patients read the guidelines on psoriasis.org, they’ll see their array of choices and self-educate,” he says. “They’ll ask, ‘What can I do?’ ‘Where can I go next?’ ”
The Art of Medicine
M. Elaine Husni, M.D., MPH, a rheumatologist at the Cleveland Clinic in Ohio, is a member of the NPF board of directors. She is the vice chair of rheumatology and director of the Arthritis and Musculoskeletal Center at Cleveland Clinic. She’s also held offices with ACR and is a co-author of the Journal of Psoriasis and Psoriatic Arthritis/Arthritis & Rheumatology article. She explains that the recommendations in the treatment guideline “are meant to create a consensus. They are not meant to be strictly followed,” she says. “These guidelines for psoriatic arthritis are updates because of the explosion of new treatments in recent years.”
Husni is enthusiastic about the ACR/NPF PsA guideline, and not just because she spent two years working on it. The guideline process included several firsts for an organization of doctors, scientists and health professionals. She cites two:
- ACR not only collaborated with an outside group, NPF, it also worked with patients. “This was not just a big bunch of loud experts in a room,” she says. “We had patients on the panel. There were patients around the table listening. That was awesome.”
- ACR adopted a “treat to target” approach to psoriasis for psoriatic arthritis: The doctor and her patient set targets for improvement and change how they manage the patient’s disease if targets aren’t met.
The recommendations in the ACR/NPF PsA guideline are helpful and necessary, Husni says, but ultimately, patient care all comes down to what she calls “the art of medicine,” based on “my clinical intuition, my rapport with the patient and my interpretation of the clinical guidelines.” She says that physicians in most disease states like to consult clinical care practice guidelines, but that “all treatment choices still need to be discussed with the patient.”