Table 2

Treatment recommendations for peripheral spondyloarthritis and psoriatic arthritis

SourcePeripheral spondyloarthritisPsoriatic arthritis
ASAS-EULAR 201772NICE 202173ACR-NPF 2018EULAR 202074GRAPPA 202115
First lineNSAIDsNSAIDs
(adjunct therapy)
(adjunct therapy)
Local corticosteroids injectionsLocal or intramuscular corticosteroidsLocal or intramuscular corticosteroids
Second linecs-DMARDs (Sulfasalazine)cs-DMARDs
(two trials)
PDE4i (can be used as additional therapy)
cs-DMARDs (Methotrexate preferred for skin)
(Skip this step if axial disease, enthesitis)
Domain Approach
cs-DMARDs (mostly Methotrexate)
(Skip this step if axial disease, IBD, uveitis)
Third lineTNFi, IL17iTNFi, PDE4iTNFi
IL17i or IL12/23 if severe psoriasis, contra-indication to TNFi, IBD (for IL12/123)
  • IL17i, IL12/23i preferred if relevant skin involvement

  • TNFi preferred if active axial disease

Domain Approach
If peripheral arthritis:
b-DMARDs (TNFi, IL12/23i, IL23i, CTLA4-Ig) or JAKi or PDE4i
Fourth lineTNFi, IL-17iIL17i, IL12/23i or Tofacitinib;
IL23i (if moderate to severe psoriasis)
  • ACR, American College of Rheumatology; ASAS, Assessment of SpondyloArthritis international Society; b-DMARDs, biological disease-modifying antirheumatic drugs; cs-DMARDs, conventional synthetic DMARDs; EULAR, European League of Associations for Rheumatology; GRAPPA, Group For Research And Assessment Of Psoriasis And Psoriatic Arthritis; IBD, Inflammatory Bowel Disease; IL, interleukin; JAKi, Janus Kinase inhibitor; NICE, National Institute for Health and Care Excellence; NPF, National Psoriasis Foundation; NSAIDs, non-steroidal anti-inflammatory drugs; PDE4i, phosphodiesterase 4 inhibitor; TNFi, Tumour Necrosis Factor inhibitor.