Table 6 Guidelines of the Brazilian Society of Rheumatology for the diagnosis and treatment of psoriatic arthritis with their respective level of evidence, strength of recommendation and degree of agreement among experts (interrater reliability), 2020

1

What are the criteria for considering that an individual has psoriatic arthritis?

The diagnosis of PsA should be based on clinical and imaging criteria, and the CASPAR should be used for disease classification

1A

A

The use of PsA screening questionnaires in patients with PsO is recommended, with preference for those that have already been validated in the Brazilian population, such as the PASE, PEST and TOPAS-II

1A

A

2

Is there a correlation between skin, nail and osteoarticular manifestations in psoriatic arthritis?

All patients with PsO should be evaluated for the presence of musculoskeletal manifestations, and those with involvement of the nails, intergluteal region, scalp or of extensive areas are at higher risk for musculoskeletal involvement

2B

B

3

What are the comorbidities most associated with psoriatic arthritis?

The most frequent comorbidities in patients with PsA, such as metabolic syndrome, atherosclerosis, cardiovascular disease, mood disorders, inflammatory bowel disease, osteoporosis and uveitis, should be screened and managed

2B

B

4

Is there evidence of benefits of exercise in the treatment of psoriatic arthritis?

Aerobic and resistance exercises should be individually prescribed to improve functional capacity, pain and quality of life

1B

A

5

What is the evidence for the use of corticosteroids in patients with psoriatic arthritis?

The use of intra-articular corticosteroid injection is recommended for localized, mono- or oligoarticular disease, especially in patients who are unresponsive to systemic treatment

2C

B

Due to the lack of quality data on the efficacy of the use of systemic corticosteroids in PsA and the known adverse effects, their long-term use is not recommended

5

D

6

What is the evidence for the use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients with psoriatic arthritis?

The use of NSAIDs is recommended as a symptomatic treatment in patients with peripheral arthritis

1B

A

The use of NSAIDs is recommended as a symptomatic treatment in patients with enthesitis, dactylitis and axial manifestations

5

D

As there is no evidence of a difference in efficacy among NSAIDs*, the choice of the drug should be based on the physician's familiarity with the drug and individual patient preference, respecting the concomitant clinical conditions**

*1B**5

B

7

What is the evidence for the use of conventional DMARDs in the treatment of psoriatic arthritis?

The use of methotrexate (MTX) is recommended as the first option among cDMARDs for the treatment of peripheral articular and skin involvement in PsA*, preferably at doses higher than 15 mg/week and subcutaneously**.

*1B

**5

B

If MTX is not available, cyclosporine, leflunomide or sulfasalazine should be used in patients with peripheral arthritis

2B

B

There is NO scientific evidence of the use of cDMARDs in axial disease and limited evidence for enthesitis

5

D

8

When are biologic DMARDs or targeted synthetic DMARDs indicated for the treatment of PsA?

A bDMARD should be initiated in patients with PsA and peripheral arthritis who remain with active disease despite the use of a cDMARD, preferably MTX, for at least 3 months

1B

A

In the case of failure or inability to use a bDMARD, a tsDMARD can be used

1B

B

The use of a bDMARD is recommended for patients with PsA and axial manifestations who remain with active disease despite the use of 2 classes of NSAIDs, in full dose, for at least 30 days each

1B

B

9

Is there a difference in the efficacy of biologic DMARDs and targeted synthetic DMARDs in the treatment of PsA?

For the treatment of peripheral arthritis, dactylitis and enthesitis, the use of any of the following drugs is recommended: anti-TNFs (adalimumab, certolizumab pegol, etanercept, golimumab and infliximab), anti-IL-17 (ixekizumab and secukinumab), anti-IL-12/23 (ustekinumab) and anti-IL-23 (guselkumab)

1B

A

The choice of drug should take into account patient preference (in regard to the route of administration and frequency of use, for example), concomitant clinical conditions, medical history (e.g., history of tuberculosis, fungal infections, and herpes zoster), cost, availability in the health system and presence of extra-articular manifestations of PsA

5

D

In patients with axial manifestations, the use of anti-TNF and anti-IL-17 drugs is preferentially recommended

1B

B

In patients with PsA and severe PsO, anti-IL-23, anti-IL-17, and anti-IL-12/23 drugs are preferentially recommended over anti-TNFs

1B

A

In patients with recurrent uveitis, the use of anti-TNF monoclonal antibodies is recommended

1B

B

In patients with concomitant active Crohn's disease, the use of IFX, ADA, CTZ, and UST is preferentially recommended

1B

B

In patients with concomitant active ulcerative colitis, the use of IFX, ADA, GOL, UST or TOF is preferentially recommended

1B

B

10

Is there a difference in the safety of biologic DMARDs in the treatment of PsA?

Screening and treatment of latent tuberculosis infection (LTBI) or disease is recommended before the use of any immunobiologic and JAK inhibitor

2B

B

In general, the biologics used for the treatment of PsA have similar safety profiles, and the particularities inherent to the cytokine to be inhibited should be considered

1B

B

The use of anti-TNFs in patients with demyelinating disease or class III or IV heart failure is not recommended

4

C

The use of JAK inhibitors in patients with disseminated or recurrent herpes zoster is not recommended

1B

A

The use of IL-17 inhibitors in patients with a history of severe or recurrent fungal infections is not recommended

1B

A

11

Is there evidence for the use of conventional DMARDs combined with biologic DMARDs or target synthetic DMARDs?

Regarding monoclonal anti-TNF biologics, the concomitant use of MTX is recommended to increase survival, although there is no evidence of increased efficacy

*2B

**1B

B

Regarding non-anti-TNF biologics or tsDMARDs, there is no evidence of increased efficacy or survival with the concomitant use of cDMARDs

1B

A

12

Is there evidence for switching biologic and small-molecule DMARDs in patients with psoriatic arthritis?

In patients with PsA and bDMARD failure, switching to any other immunobiologic agent or to JAK inhibitors is recommended, with no differences between drugs, and the most relevant manifestations of the disease and concomitant clinical conditions should be considered

*1B

**5

B

When the therapeutic failure of an anti-TNF agent is attributed to skin inflammatory activity, switching to drugs with another mechanism of action, such as anti-IL23, anti-IL17 or anti-IL-12/23 agents, can be evaluated

1B

B

When the therapeutic failure of an anti-TNF agent is attributed to serious adverse events, especially infections, switching to drugs with another mechanism of action, such as anti-IL-17, anti-IL-12/23, and anti-IL23 drugs or CTLA4 inhibitors

2B

B

If there is a preference for oral medication or contraindications to injectable medications, the use of tofacitinib may be considered

5

D