Summary

First joint ACR/NPF guideline for treating active psoriatic arthritis (PsA), using GRADE methodology to address pharmacologic and nonpharmacologic management in treatment-naive patients, those failing prior therapy, and special populations (axial disease, enthesitis, IBD, diabetes, recurrent infections). Notably recommends TNF inhibitor biologics as first-line over oral small molecules (OSMs) in most treatment-naive patients with active PsA—a departure from EULAR/GRAPPA which preferred OSMs first. Endorses a treat-to-target strategy, smoking cessation, and vaccination considerations around biologic initiation. 94% of recommendations are conditional based on low/very-low-quality evidence.

Key Recommendations

In treatment-naive active PsA, start a TNF inhibitor biologic over an OSM (MTX, SSZ, LEF, CSA, apremilast); OSM acceptable if disease not severe, patient prefers oral, or TNFi contraindicated (CHF, recurrent/serious infections, demyelinating disease).
In treatment-naive PsA, choose TNFi over IL-17i or IL-12/23i; IL-17i or IL-12/23i preferred if severe psoriasis or TNFi contraindicated; IL-12/23i preferred over IL-17i if concomitant IBD.
Methotrexate is preferred over NSAIDs in treatment-naive active PsA.
For active PsA despite an OSM, switch to a TNFi biologic over another OSM, IL-17i, IL-12/23i, abatacept, or tofacitinib (TNFi is the preferred next step).
Biologic monotherapy is preferred over biologic + MTX combination; continue MTX with monoclonal antibody TNFi (infliximab, adalimumab) to reduce immunogenicity, severe psoriasis, partial MTX response, or concomitant uveitis.
After TNFi monotherapy failure, switch to a different TNFi rather than to IL-17i, IL-12/23i, abatacept, or tofacitinib; switch class if primary TNFi failure or serious adverse event.
Use a treat-to-target strategy in active PsA.
For axial/spondylitis PsA failing NSAIDs, use a TNFi biologic; IL-17i is second-line; do NOT use IL-12/23i (failed axial SpA trials).
For active PsA with concomitant active IBD, STRONGLY recommend a monoclonal antibody TNFi (not etanercept) or IL-12/23i over IL-17i (which can worsen IBD).
For active PsA with frequent serious infections, STRONGLY recommend starting an OSM over a TNFi biologic (TNFi black-box warning); IL-12/23i or IL-17i preferred over TNFi.
In PsA with diabetes, prefer an OSM other than methotrexate over a TNFi as first-line (MTX hepatotoxicity risk with fatty liver).
Start biologic and give killed vaccines concurrently; delay biologic initiation to administer live attenuated vaccines; STRONGLY recommend smoking cessation, plus low-impact exercise, physical/occupational therapy, weight loss for overweight/obese patients.

Thresholds & Doses

Severe psoriasis (clinical trial definition): PASI ≥12 AND body surface area ≥10%.
Moderate-to-severe psoriasis (2007 NPF expert consensus): body surface area ≥5%, or involvement of face/hands/feet/nails/intertriginous/scalp regardless of BSA.
Voting Panel consensus threshold: ≥70% agreement required to issue a recommendation.
Distribution of recommendations: 6% strong, 94% conditional.
Nail involvement prevalence in PsA: ~80–90% of patients.
Annual incidence of PsA in psoriasis patients: 2.7%; PsA prevalence in psoriasis: 6–41%.
Peripheral arthritis pattern definitions: oligoarthritis ≤4 joints, polyarthritis ≥5 joints.

Citations

Table 1 / Figure 3 — Recommendations for OSM- and treatment-naive active PsA (TNFi preferred first-line).
Table 2 / Figure 4 — Recommendations after inadequate response to an OSM.
Table 3 / Figure 5 — Recommendations after TNFi monotherapy or TNFi+MTX failure.
Table 4 / Figure 6 — Recommendations after IL-17i or IL-12/23i monotherapy failure.
Table 5 — Treat-to-target, axial disease, enthesitis, and concomitant IBD recommendations (strong recommendations for monoclonal TNFi/IL-12/23i over IL-17i in IBD).
Table 6 — Comorbidities: diabetes (non-MTX OSM preferred) and frequent serious infections (strong recommendation for OSM over TNFi).
Table 7 — Vaccination recommendations around biologic initiation (killed vs. live attenuated).
Table 8 — Nonpharmacologic interventions including strong recommendation for smoking cessation.