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Dermatologists Excluded From PsA Recommendation Task Force

ROME - "No dermatologists wanted" was the apparent message sent by a task force that prepared a new set of recommendations for managing patients with psoriatic arthritis on behalf of the European League Against Rheumatism (EULAR).

By design, the panel that wrote the recommendations consisted entirely of rheumatologists, a fact proudly announced by French rheumatologist Laure Gossec as she gave the first public presentation of the recommendations during a session of the congress.

"Our goal was to develop easy-to-apply management recommendations for pharmacological, nontopical treatment from the rheumatologists point of view," according to Dr. Gossec, who is a rheumatologist at Cochin Hospital in Paris.

The parochial genesis of the new EULAR recommendations contrasts with another authoritative set of psoriatic arthritis (PsA) management recommendations published last year by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) (Ann. Rheum. Dis. 2009;68:1387-94), a document that involved participation by dermatologists.

The timing also raised questions on why the world needed a second guide to managing PsA so soon.

"We felt that the GRAPPA recommendations were rather complex to apply for rheumatologists. They require distinguishing mild, moderate, and severe disease and features of the disease," said Dr. Gossec.

In addition, creation of the GRAPPA recommendations, published in 2009, involved a high representation of dermatologists and were applicable to patients with high skin involvement, she said.

Drafting of the new EULAR recommendations began last January and finished in June, just days before Dr. Gossec presented them.

Dr. Christopher T. Ritchlin

Some of this rationale is reasonable, said Dr. Christopher T. Ritchlin, a rheumatologist at the University of Rochester, N.Y., who chaired the GRAPPA panel that produced the 2009 treatment recommendations and was also a member of the EULAR task force that created the new guidelines.

"They're trying to be simple, which is fine. This is a great effort. I completely applaud trying to simplify, but that can be challenging because psoriatic arthritis is not only heterogeneous but can be complex within a patient. The GRAPPA recommendations are very complex; they took 2 years to develop. We worked with dermatologists because we felt there needs to be co-management for a large number of patients to effectively take care of their psoriatic disease. Interaction of the rheumatologist and dermatologist and even a psychologist or psychiatrist is critical for the successful management of a large number of cases. Not for every patient; some patients have no skin involvement. But there are a lot who have skin involvement."

Most dermatologists would likely agree.

Dr. Craig L. Leonardi

"I think it is important for dermatologists to have a seat at the table," said Dr. Craig L. Leonardi, a dermatologist and psoriasis specialist at St. Louis University. "Results from published studies show that roughly 70% of PsA patients have skin symptoms before joint symptoms and, on average, they had skin symptoms for 10 years. If patients are pursuing treatment for their psoriasis, it may be a dermatologist who detects early PsA first. As a consequence, recommendations for early diagnosis and treatment need to consider the dermatologist."

Dr. Leonardi acknowledged that "rheumatologists are the ones formally trained in managing inflammatory joint disease. But there are some things about managing psoriasis that rheumatologists may not be aware of. For example, psoriatic skin has a wide range of responses to the various tumor necrosis factor antagonists" which should play a role in drug selection, he said.

A more skeptical view of the need for a new set of recommendations so soon on the heels of the GRAPPA paper came from Dr. Dafna D. Gladman, another member of the GRAPPA panel who had no involvement with the EULAR task force. "The EULAR group didn't come up with any more papers than GRAPPA. I'm not sure we have more information here than in the GRAPPA recommendations. I feel the GRAPPA recommendations are more helpful to clinicians because they tell them exactly what to do" for PsA patients with very specific disease presentations, he said.

"I'm not impressed that these recommendations are anything new," said Dr. Gladman, professor of medicine at the University of Toronto and director of the psoriatic arthritis program at Toronto Western Hospital.

During the brief discussion of the new EULAR recommendations following Dr. Gossec's presentation, most attention focused on the role of methotrexate and tumor necrosis factor (TNF) inhibitors for treating PsA.

The recommendations "emphasize how much we need controlled trial data on methotrexate," said Dr. Ritchlin.

One of the 10 recommendations from the EULAR panel gave the green light to starting treatment with a TNF inhibitor "in patients with active arthritis and an inadequate response to at least one synthetic disease-modifying antirheumatic drug, such as methotrexate."

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