Primary Care/Internal Medicine

NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.

"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.

"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.

"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.

Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.

This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.

The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.

For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.

Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.

Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.

"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."

When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.

Dr. Siegel reported financial relationships with Amgen and AbbVie.

NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.

"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.

"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.

"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.

Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.

This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.

The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.

For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.

Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.

Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.

"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."

When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.

Dr. Siegel reported financial relationships with Amgen and AbbVie.

NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.

"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.

"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.

"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.

Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.

This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.

The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.

For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.

Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.

Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.

"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."

When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.

Dr. Siegel reported financial relationships with Amgen and AbbVie.

COEUR D’ALENE, IDAHO – The 2014 American Academy of Dermatology atopic dermatitis guidelines may already need an update, according to the cochair of the guidelines panel.

The guidelines were based upon studies published through 2012. Since then, new evidence has emerged that raises the level of uncertainty regarding several key questions the panel addressed, Dr. Robert Sidbury observed at the annual meeting of the Society for Pediatric Dermatology. Among these questions: To bathe or not to bathe? Will a child outgrow atopic dermatitis?

©aniaostudio/thinkstockphotos.com

Serving as cochair of the guidelines committee was both a reassuring and daunting experience, according to Dr. Sidbury, chief of the division of dermatology at Seattle Children’s Hospital.

It was reassuring to note that the committee members, who included 17 atopic dermatitis experts from three countries, were free from financial conflicts as they sifted through the published data for evidence-based recommendations to inform practice. But it was daunting to learn how sketchy the supporting evidence is for some of the conventional wisdom regarding atopic dermatitis management, he explained.

By way of providing what he called "a peek behind the curtains" of the guidelines-development process, Dr. Sidbury highlighted the issue of daily bathing followed by application of emollients and moisturizers. This was among the topics the panel struggled with the most, which might come as a surprise to outsiders who consider this to be standard practice, he noted.

"It seems like a very straightforward thing. Almost everyone in this room, to a person, recommends a daily bath followed by moisturizers, yet when we examined the studies we realized that recommendation isn’t based upon much evidence," he said.

Thus, the panel concluded that bathing is "suggested" for atopic dermatitis patients, while adding that "there is no standard" for the duration or frequency of bathing. The panel rated the strength of their recommendation as C, and the level of evidence as III.

"That’s a fairly weak recommendation based upon fairly week evidence," Dr. Sidbury commented.

Moreover, since publication of the guidelines, two new studies have come forth that address the question of whether bathing plus moisturizers is beneficial in atopic dermatitis. The results conflict with each other, making recommendations even more difficult.

Data from a retrospective study of 75 patients with moderate or severe atopic dermatitis suggested that a daily 15- to 20-minute bath followed by a mid-potency topical steroid and moisturizer was indeed beneficial: 79% of subjects showed marked improvement based on Investigator’s Global Assessment at week 3, and 4% were clear (Dermatitis 2014;25:56-9).

By contrast, data from a prospective trial in which 28 children with atopic dermatitis were randomized to a daily vs. twice-weekly bath followed by appropriate care indicated that, while hydration with emollients was important, bathing frequency wasn’t (Clin. Pediatr. 2014;53:677-81).

"This paper makes me feel better about the guidelines not saying, ‘You should bathe every day,’ although that’s still my own recommendation to patients," Dr. Sidbury said.

This year also has brought two conflicting studies regarding the natural history of atopic dermatitis. A large national Taiwanese population-based cohort study of children diagnosed with atopic dermatitis within the first 2 years of life and followed from birth to age 10 years concluded that 70% of these early-onset patients eventually went into remission. A total of 19% of patients did so within the first year, and 49% in less than 4 years. The median disease duration was 4.2 years (Br. J. Dermatol. 2014;170:130-5).

On the other hand, a report from the 7,157-patient, cross-sectional, longitudinal Pediatric Eczema Elective Registry (PEER) found that by age 20, only 50% of the patients had experienced at least one symptom-free period lasting 6 months or more. The investigators concluded that atopic dermatitis is probably a lifelong disease (JAMA Dermatology 2014;150:593-600).

"That’s a provocative conclusion, and a tough thing to tell a parent," Dr. Sidbury observed. "I offer parents realistic but optimistic counsel. I tell them the tendency toward xerosis, irritancy, and infection will persist – the patient in front of you is never going to want to wear a wool sweater for the rest of their life. But the incessant itch, the need for treatment, the impact on quality of life – which is really the issue at hand – hopefully will not persist."

Since the release earlier this year of the first three of the four sections of the atopic dermatitis guidelines, Dr. Sidbury and the other panelists have received considerable feedback that the guidelines didn’t adequately address the topic of topical steroid addiction.

"Some say we missed the boat in not making coherent recommendations to parents about it. We got some very pointed comments," he conceded.

He noted that a systematic review presented at last year’s International Symposium on Atopic Dermatitis concluded that topical steroid withdrawal is a real phenomenon distinct from other topical steroid side effects. It comes in two rosacea-like variants: an erythroedematous form and a papulopustular form. An atopic dermatitis patient’s report of a burning sensation upon cessation of topical steroid therapy is a red flag.

Despite the occasional missed opportunity in drawing up the first AAD atopic guidelines in 10 years, the process was richly rewarding, Dr. Sidbury said. And although experts will continue to debate the unresolved controversies in atopic dermatitis, for him the most important lesson to emerge from the panel’s comprehensive review of the evidence was strikingly clear: "Time and time again, education trumps all. Education of patients and families leads to the best outcomes. I think that’s an important lesson to take home," he said.

Dr. Sidbury had no financial conflicts to disclose.

[email protected]

COEUR D’ALENE, IDAHO – The 2014 American Academy of Dermatology atopic dermatitis guidelines may already need an update, according to the cochair of the guidelines panel.

The guidelines were based upon studies published through 2012. Since then, new evidence has emerged that raises the level of uncertainty regarding several key questions the panel addressed, Dr. Robert Sidbury observed at the annual meeting of the Society for Pediatric Dermatology. Among these questions: To bathe or not to bathe? Will a child outgrow atopic dermatitis?

©aniaostudio/thinkstockphotos.com

Serving as cochair of the guidelines committee was both a reassuring and daunting experience, according to Dr. Sidbury, chief of the division of dermatology at Seattle Children’s Hospital.

It was reassuring to note that the committee members, who included 17 atopic dermatitis experts from three countries, were free from financial conflicts as they sifted through the published data for evidence-based recommendations to inform practice. But it was daunting to learn how sketchy the supporting evidence is for some of the conventional wisdom regarding atopic dermatitis management, he explained.

By way of providing what he called "a peek behind the curtains" of the guidelines-development process, Dr. Sidbury highlighted the issue of daily bathing followed by application of emollients and moisturizers. This was among the topics the panel struggled with the most, which might come as a surprise to outsiders who consider this to be standard practice, he noted.

"It seems like a very straightforward thing. Almost everyone in this room, to a person, recommends a daily bath followed by moisturizers, yet when we examined the studies we realized that recommendation isn’t based upon much evidence," he said.

Thus, the panel concluded that bathing is "suggested" for atopic dermatitis patients, while adding that "there is no standard" for the duration or frequency of bathing. The panel rated the strength of their recommendation as C, and the level of evidence as III.

"That’s a fairly weak recommendation based upon fairly week evidence," Dr. Sidbury commented.

Moreover, since publication of the guidelines, two new studies have come forth that address the question of whether bathing plus moisturizers is beneficial in atopic dermatitis. The results conflict with each other, making recommendations even more difficult.

Data from a retrospective study of 75 patients with moderate or severe atopic dermatitis suggested that a daily 15- to 20-minute bath followed by a mid-potency topical steroid and moisturizer was indeed beneficial: 79% of subjects showed marked improvement based on Investigator’s Global Assessment at week 3, and 4% were clear (Dermatitis 2014;25:56-9).

By contrast, data from a prospective trial in which 28 children with atopic dermatitis were randomized to a daily vs. twice-weekly bath followed by appropriate care indicated that, while hydration with emollients was important, bathing frequency wasn’t (Clin. Pediatr. 2014;53:677-81).

"This paper makes me feel better about the guidelines not saying, ‘You should bathe every day,’ although that’s still my own recommendation to patients," Dr. Sidbury said.

This year also has brought two conflicting studies regarding the natural history of atopic dermatitis. A large national Taiwanese population-based cohort study of children diagnosed with atopic dermatitis within the first 2 years of life and followed from birth to age 10 years concluded that 70% of these early-onset patients eventually went into remission. A total of 19% of patients did so within the first year, and 49% in less than 4 years. The median disease duration was 4.2 years (Br. J. Dermatol. 2014;170:130-5).

On the other hand, a report from the 7,157-patient, cross-sectional, longitudinal Pediatric Eczema Elective Registry (PEER) found that by age 20, only 50% of the patients had experienced at least one symptom-free period lasting 6 months or more. The investigators concluded that atopic dermatitis is probably a lifelong disease (JAMA Dermatology 2014;150:593-600).

"That’s a provocative conclusion, and a tough thing to tell a parent," Dr. Sidbury observed. "I offer parents realistic but optimistic counsel. I tell them the tendency toward xerosis, irritancy, and infection will persist – the patient in front of you is never going to want to wear a wool sweater for the rest of their life. But the incessant itch, the need for treatment, the impact on quality of life – which is really the issue at hand – hopefully will not persist."

Since the release earlier this year of the first three of the four sections of the atopic dermatitis guidelines, Dr. Sidbury and the other panelists have received considerable feedback that the guidelines didn’t adequately address the topic of topical steroid addiction.

"Some say we missed the boat in not making coherent recommendations to parents about it. We got some very pointed comments," he conceded.

He noted that a systematic review presented at last year’s International Symposium on Atopic Dermatitis concluded that topical steroid withdrawal is a real phenomenon distinct from other topical steroid side effects. It comes in two rosacea-like variants: an erythroedematous form and a papulopustular form. An atopic dermatitis patient’s report of a burning sensation upon cessation of topical steroid therapy is a red flag.

Despite the occasional missed opportunity in drawing up the first AAD atopic guidelines in 10 years, the process was richly rewarding, Dr. Sidbury said. And although experts will continue to debate the unresolved controversies in atopic dermatitis, for him the most important lesson to emerge from the panel’s comprehensive review of the evidence was strikingly clear: "Time and time again, education trumps all. Education of patients and families leads to the best outcomes. I think that’s an important lesson to take home," he said.

Dr. Sidbury had no financial conflicts to disclose.

[email protected]

COEUR D’ALENE, IDAHO – The 2014 American Academy of Dermatology atopic dermatitis guidelines may already need an update, according to the cochair of the guidelines panel.

The guidelines were based upon studies published through 2012. Since then, new evidence has emerged that raises the level of uncertainty regarding several key questions the panel addressed, Dr. Robert Sidbury observed at the annual meeting of the Society for Pediatric Dermatology. Among these questions: To bathe or not to bathe? Will a child outgrow atopic dermatitis?

©aniaostudio/thinkstockphotos.com

Serving as cochair of the guidelines committee was both a reassuring and daunting experience, according to Dr. Sidbury, chief of the division of dermatology at Seattle Children’s Hospital.

It was reassuring to note that the committee members, who included 17 atopic dermatitis experts from three countries, were free from financial conflicts as they sifted through the published data for evidence-based recommendations to inform practice. But it was daunting to learn how sketchy the supporting evidence is for some of the conventional wisdom regarding atopic dermatitis management, he explained.

By way of providing what he called "a peek behind the curtains" of the guidelines-development process, Dr. Sidbury highlighted the issue of daily bathing followed by application of emollients and moisturizers. This was among the topics the panel struggled with the most, which might come as a surprise to outsiders who consider this to be standard practice, he noted.

"It seems like a very straightforward thing. Almost everyone in this room, to a person, recommends a daily bath followed by moisturizers, yet when we examined the studies we realized that recommendation isn’t based upon much evidence," he said.

Thus, the panel concluded that bathing is "suggested" for atopic dermatitis patients, while adding that "there is no standard" for the duration or frequency of bathing. The panel rated the strength of their recommendation as C, and the level of evidence as III.

"That’s a fairly weak recommendation based upon fairly week evidence," Dr. Sidbury commented.

Moreover, since publication of the guidelines, two new studies have come forth that address the question of whether bathing plus moisturizers is beneficial in atopic dermatitis. The results conflict with each other, making recommendations even more difficult.

Data from a retrospective study of 75 patients with moderate or severe atopic dermatitis suggested that a daily 15- to 20-minute bath followed by a mid-potency topical steroid and moisturizer was indeed beneficial: 79% of subjects showed marked improvement based on Investigator’s Global Assessment at week 3, and 4% were clear (Dermatitis 2014;25:56-9).

By contrast, data from a prospective trial in which 28 children with atopic dermatitis were randomized to a daily vs. twice-weekly bath followed by appropriate care indicated that, while hydration with emollients was important, bathing frequency wasn’t (Clin. Pediatr. 2014;53:677-81).

"This paper makes me feel better about the guidelines not saying, ‘You should bathe every day,’ although that’s still my own recommendation to patients," Dr. Sidbury said.

This year also has brought two conflicting studies regarding the natural history of atopic dermatitis. A large national Taiwanese population-based cohort study of children diagnosed with atopic dermatitis within the first 2 years of life and followed from birth to age 10 years concluded that 70% of these early-onset patients eventually went into remission. A total of 19% of patients did so within the first year, and 49% in less than 4 years. The median disease duration was 4.2 years (Br. J. Dermatol. 2014;170:130-5).

On the other hand, a report from the 7,157-patient, cross-sectional, longitudinal Pediatric Eczema Elective Registry (PEER) found that by age 20, only 50% of the patients had experienced at least one symptom-free period lasting 6 months or more. The investigators concluded that atopic dermatitis is probably a lifelong disease (JAMA Dermatology 2014;150:593-600).

"That’s a provocative conclusion, and a tough thing to tell a parent," Dr. Sidbury observed. "I offer parents realistic but optimistic counsel. I tell them the tendency toward xerosis, irritancy, and infection will persist – the patient in front of you is never going to want to wear a wool sweater for the rest of their life. But the incessant itch, the need for treatment, the impact on quality of life – which is really the issue at hand – hopefully will not persist."

Since the release earlier this year of the first three of the four sections of the atopic dermatitis guidelines, Dr. Sidbury and the other panelists have received considerable feedback that the guidelines didn’t adequately address the topic of topical steroid addiction.

"Some say we missed the boat in not making coherent recommendations to parents about it. We got some very pointed comments," he conceded.

He noted that a systematic review presented at last year’s International Symposium on Atopic Dermatitis concluded that topical steroid withdrawal is a real phenomenon distinct from other topical steroid side effects. It comes in two rosacea-like variants: an erythroedematous form and a papulopustular form. An atopic dermatitis patient’s report of a burning sensation upon cessation of topical steroid therapy is a red flag.

Despite the occasional missed opportunity in drawing up the first AAD atopic guidelines in 10 years, the process was richly rewarding, Dr. Sidbury said. And although experts will continue to debate the unresolved controversies in atopic dermatitis, for him the most important lesson to emerge from the panel’s comprehensive review of the evidence was strikingly clear: "Time and time again, education trumps all. Education of patients and families leads to the best outcomes. I think that’s an important lesson to take home," he said.

Dr. Sidbury had no financial conflicts to disclose.

[email protected]

NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.

"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.

The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.

The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.

Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.

For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."

For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.

The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.

For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."

One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.

"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.

The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.

Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.

NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.

"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.

The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.

The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.

Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.

For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."

For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.

The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.

For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."

One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.

"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.

The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.

Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.

NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.

"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.

The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.

The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.

Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.

For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."

For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.

The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.

For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."

One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.

"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.

The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.

Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.