Guidelines for the treatment of psoriatic arthritis with biologics

Recommendation one
Anti‐TNF therapy should be considered for those patients with active arthritis (defined as at least 3 tender and
3 swollen joints) who have failed treatment with at least 2 conventional DMARDs*. Anti‐TNF therapy may be
considered for patients who have failed only one DMARD especially where there is evidence of adverse
prognostic factors** (Grade A)
*e.g. leflunomide, methotrexate, sulfasalazine, ciclosporin
** adverse prognostic factors defined as 5 or more swollen joints with elevated CRP persisting for more than 3
months, and/or structural joint damage due to disease, and/or previous use of oral corticosteroids
Recommendation two
All of the licensed anti‐TNF therapies are recommended for use in patients eligible for treatment and choice of
therapy should be left to the treating physician after considering concomitant medical problems, patient
preference and cost effectiveness. For patients requiring rapid control of skin psoriasis an anti‐TNF monoclonal
antibody is preferred in accordance with British Association of Dermatology (BAD) guidelines 2 (Grade A)
Recommendation three
The Psoriatic Arthritis Response Criteria (PsARC) are recommended as the clinical response criteria for
peripheral psoriatic arthritis and a Psoriasis Area Severity Index (PASI) score should be completed for patients
with skin psoriasis. In future, following appropriate validation, static composite measures evaluating all
aspects of psoriatic disease should be used to assess eligibility and response in PsA. (Grade A)
Recommendation four
Anti‐TNF therapies should be continued in patients who have responded after three months or treatment. In
the case of non‐responders, consideration should be given to a further 12 weeks of therapy if there has been a
partial response*and then continuing therapy if there has been a full response compared to baseline (Grade B)
*A partial response is defined by some improvement in swollen and tender joint score and no worsening in
physician or patient global score as measured by the PsARC
Recommendation five
Anti‐TNF therapies should be considered in patients with severe persistent oligoarthritis, that has a major
demonstrable influence on well‐being and who have failed treatment with at least 2 conventional DMARDs and
appropriate intra‐articular therapy (Grade C)
Recommendation six
Anti‐TNF therapy should be considered for those patients with active axial psoriatic disease according to the
recommendation of the BSR guidelines for ankylosing spondylitis 3 (Grade A)
Recommendation seven
In the case of failure of an anti‐TNF therapy, either due to inefficacy or toxicity, an alternative anti‐TNF therapy
should be considered and response to treatment assessed as for the first anti‐TNF agent (Grade B)
Recommendation eight
Prior to starting treatment with anti‐TNF therapy all patients should be screened for mycobacterial infection in
accordance with the latest National guidelines. Active mycobacterial infection should be adequately treated
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