Objective New modes of action and more data on the efficacy and safety of existing
drugs in psoriatic arthritis (PsA) required an update of the EULAR 2019 recommendations
for the pharmacological treatment of PsA. Methods Following EULAR standardised operating
procedures, the process included a systematic literature review and a consensus meeting
of 36 international experts in April 2023. Levels of evidence and grades of recommendations
were determined. Results The updated recommendations comprise 7 overarching principles
and 11 recommendations, and provide a treatment strategy for pharmacological therapies.
Non-steroidal anti-inflammatory drugs should be used in monotherapy only for mild
PsA and in the short term; oral glucocorticoids are not recommended. In patients with
peripheral arthritis, rapid initiation of conventional synthetic disease-modifying
antirheumatic drugs is recommended and methotrexate preferred. If the treatment target
is not achieved with this strategy, a biological disease-modifying antirheumatic drug
(bDMARD) should be initiated, without preference among modes of action. Relevant skin
psoriasis should orient towards bDMARDs targeting interleukin (IL)-23p40, IL-23p19,
IL-17A and IL-17A/F inhibitors. In case of predominant axial or entheseal disease,
an algorithm is also proposed. Use of Janus kinase inhibitors is proposed primarily
after bDMARD failure, taking relevant risk factors into account, or in case bDMARDs
are not an appropriate choice. Inflammatory bowel disease and uveitis, if present,
should influence drug choices, with monoclonal tumour necrosis factor inhibitors proposed.
Drug switches and tapering in sustained remission are also addressed. Conclusion These
updated recommendations integrate all currently available drugs in a practical and
progressive approach, which will be helpful in the pharmacological management of PsA.
