Guidelines for the treatment of psoriatic arthritis with biologics

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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 32
efore anti‐TNF therapy is started. Prior to starting anti‐TNF therapy consideration of prophylactic anti‐TB therapy (as directed by the latest National guidelines) should be given to patients with evidence of potential latent disease (Grade B). Physicians should be vigilant for the development of mycobacterial infections throughout treatment with anti‐TNF and for at least 6 months after discontinuation (Grade C). If patients develop evidence of mycobacterial infection whilst on anti‐TNF therapy they should receive a full course of antimycobacterial chemotherapy – the anti‐TNF therapy may be continued during this time if clinically indicated (Grade C) 4 . Recommendation nine Anti‐TNF therapy should not be initiated or continued in the presence of serious active infection, but can be recommenced once the infection has resolved clinically (Grade B). Anti‐TNF therapy should be used with caution in patients at high infection risk after discussing the relative risks and benefits (Grade C). 4 Recommendation ten Patients on anti‐TNF therapy should be informed of appropriate food hygiene. There should be a high index of suspicion for the possibility of atypical or opportunistic infections, and treatment should be stopped and advice sought in suspected cases (Grade B) 4 Recommendation eleven Patients at risk should be screened for human immunodeficiency virus (HIV), and all patients should be screened for hepatitis B virus (HBV) and hepatitis C virus (HCV) prior to anti‐TNF therapy (Grade C). HIV or HCV infection should not preclude treatment with anti‐TNF therapy although treatment should only be commenced in those with well controlled disease and with appropriate monitoring under the care of a Hepatologist or HIV specialist (Grade B). Anti‐TNF therapy in those with chronic HBV should be approached with caution given the potential risk of reactivation and fulminant hepatitis. Anti‐TNF therapy should only be commenced in those with well controlled disease, with appropriate antiviral treatment and regular monitoring in collaboration with a Hepatologist. Consideration should be given to vaccinating those at risk of HBV prior to treatment (Grade C). Recommendation twelve Anti‐TNF therapy should be avoided in patients with a current or prior history of malignancy unless the malignancy was diagnosed and treated more than 5 years ago and/or where the likelihood of cure is high. All patients should be encouraged to participate in national cancer screening programmes appropriate for their age and gender. Patients on anti‐TNF should be regularly screened for skin cancers (including melanoma) especially if their background risk is high. Anti‐TNF therapy is relatively contra‐indicated in patients who have had prior treatment with >200PUVA and/or >350 UVB treatments, especially when this has been followed by treatment with ciclosporin (Grade C) 2 Recommendation thirteen Anti‐TNF agents should ideally be stopped prior to pregnancy and restarted after end of lactation or delivery if not breast feeding. Management should be in accordance with BSR guidelines for rheumatoid arthritis 4 and the BAD guidelines (Grade C) 2 33
Page 1 and 2: GUIDELINES FOR THE TREATMENT OF PSO
Page 3 and 4: the Working Party were fully declar
Page 5 and 6: TREATMENT OF PERIPHERAL ARTHRITIS (
Page 7 and 8: Recommendations • Anti‐TNF ther
Page 9 and 10: classification criteria. Psoriasis
Page 11 and 12: Recommendations • Anti‐TNF ther
Page 13 and 14: appropriate monitoring under the ca
Page 15 and 16: Multiple open label studies and reg
Page 17 and 18: with 3mg/kg abatacept. Improvement
Page 19 and 20: • Deborah Symmons Professor of Rh
Page 21 and 22: 16 Mease PJ, Gladman DD, Ritchlin C
Page 23 and 24: 46 Carroll SS, Ludmerer S, Handt L,
Page 25 and 26: 75 National Institute for Clinical
Page 27 and 28: 105 Vieira FJ, Callado MR, Vieira W
Page 29 and 30: SECTION C - axial disease YES NO 20
Page 31: The 2011 BSR guidelines for the tre

Guidelines for the treatment of psoriatic arthritis with biologics

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