1. GRAPPA Guidelines for PsA: Considerations
GRAPPA Guidelines Mission Statement: “To develop guidelines, based upon the best scientific evidence, for the optimal treatment of patients with psoriatic arthritis (PsA).”
Guidelines: “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” Institute of Medicine
More data needed on prognostic factors (e.g.for peripheral arthritis, oligoarticular vs polyarticular; erosive vs non-erosive, +/- other features such as axial, skin, entheses, etc) to optimize stratification
PsA multifaceted: How appropriate is extrapolation of efficacy/safety data, and hence treatment guidelines, from similar conditions (psoriasis, AS, RA, etc)? Can we borrow aspects of screening, stratification, monitoring?
Guideline exigency driven by introduction of novel immunomodulatory therapies, and their expense; with sensitivity to local factors, cultural differences, economics, etc
Systematic review of available evidence has been performed and published; J Rheumatol July 2006

2. Reassess Response to Therapy and Toxicity
GRAPPA PsA Treatment Guidelines Establish Diagnosis of Psoriatic Arthritis
Peripheral Arthritis
Initiate Therapy
NSAIDs,
IA steroids,
DMARDs
(MTX, CsA, SSZ, LEF),
Biologics
(anti-TNF)
Skin and
Nail Disease
Initiate Therapy
NSAID PT
Biologics
(anti-TNF)
Axial Disease
Dactylitis
Initiate Therapy
NSAID
Injection
Biologics
(anti-TNF)
Enthesitis
Initiate Therapy
NSAID
Injection
Biologics
(anti-TNF)
Initiate Therapy
Topicals
PUVA/UVB
DMARDs (MTX,CsA,etc)
Biologics (anti-TNF, etc)
Reassess Response to Therapy and Toxicity

3. How to Use a Clinical Practice Guideline
How to Use a Clinical Practice Guideline. Hayward et al (evidenced based working group). JAMA 1995;274:570-4 &
Are the results of the study valid?
- Were all important options and outcomes clearly specified?
- Was an explicit and sensible process used to identify, select and combine the evidence? To consider the value of different outcomes?
- Is the guideline likely to account for important recent developments?
- Has the guideline been subject to peer review and testing?
What were the results?
- Are practical, clinically important recommendations made?
- How strong are the recommendations?
- What is the impact of uncertainty associated with the evidence and the values used in the guidelines?
III. Will the results help me in caring for my patients?
- Is the primary objective consistent with your objective
- Are the recommendations applicable to your patients?
See also …Shiffman et al; Ann Intern Med 2003; 139:493

4. ? ? Evidence based? treatment algorithm for Peripheral PsA
Polyarthritis
Oligoarthritis
Monoarthritis ?
Early DMARDs
SSZ (A); LFN (A); MTX (B), CyA (B)
NSAIDs (A) +/- IA corticosteroids (D) ?
Adequate therapeutic trial of 2 DMARDs ?
Respond
Anti TNF alpha
Positive Response
Failed Response

5. Attributes of Systematically Developed Guidelines
• Validity: How closely is the guideline linked to the available evidence?
• Reliability: Would a different group of developers derive similar guidelines with the same evidence?
• Reproducibility: Would different care-givers interpret and apply the guidelines similarly in similar contexts
Clarity: Are the guidelines unambiguous and precise?
• Documentation: Is the method of development transparent and clearly stated?
• Multidisciplinary: Did the developers represent more than one clinical orientation towards the clinical problems being addressed?

6. PsA Treatment Guidelines Proposal
Committees
Peripheral arthritis
SystematicReviews
Guideline development and consensus by committees and patients
Skin & Nails
Vote by GRAPPA
Axial Dx
Dactylitis
Enthesitis

7. Committees Peripheral Arthritis Skin & Nails Axial Dactylitis
E Soriano, N Mchugh, P Mease, F Behrens, M Lebwohl
Skin & Nails
H Boehneke, A Gottlieb, B Strober. D Fiorentino
Axial
P Nash. J Zochling, D Gladman
Dactylitis
P Helliwell, P Healy
Enthesitis
K de Vlam. A Adebadjo

8. Treatment Guideline Model
Peripheral arthritis (# joints, pain, function, location, damage, etc)
+ skin and/or nails (severity. location, QOL)
+ axial disease (pain, function, QOL)
+ dactylitis (pain, location, function)
+ enthesitis (pain, location, function)

9. Peripheral Arthritis Skin Enthesitis Dactylitis Spine Mild Moderate
Peripheral Arthritis
Skin
Enthesitis
Dactylitis
Spine
Mild
·    1-3 tender and/or swollen joints
·    No erosive disease on plain film
·    Function not significantly impaired
<3%
BSA
None
·    No sign or symptoms
of spinal inflammation
·    Normal Schoeber
score and normal AP pelvis form
Moderate
·    5+ tender/swollen joints
·    Normal x-rays but
Oligoarticularor polyarticular
disease that interferes w/ normal function
·    Or less than 5 T/S joints but with erosions or JSN on x-ray
>3%
And
<10%
1-3 entheseal
sites inflamed
1-3 inflamed
digits
Inflammatory back pain with a normal
AP pelvis film
Severe
·    >5 tender /swollen joints
w/ evidence of joint damage on exam
·    Arthritis mutilans
·    Oligo-or polyarticular
disease that limits ADLs
>10%
·    >3 sites
·    Entheseal
involvement in foot that
prevents
ambulation
·    Tendon rupture
·    >3 inflamed
·    Evidence of
ankylosis in
a dactylitic
joint
Symptomatic
inflammatory back
pain with radiographic
changes on plain film