GRAPPA Treatment Recommendations: An Update From the 2020 GRAPPA Annual Meeting

Key Domains of PsA

The GRAPPA treatment recommendations committee made a decision to continue with a domain-based approach to the treatment recommendations, with the major change in 2020 being the split of the comorbidities group into 2 groups addressing associated conditions (i.e., inflammatory bowel disease and uveitis [eye inflammation]). Each of these domain groups developed PICO (Patient/Population – Intervention – Comparison/Comparator – Outcome) questions to guide the subsequent systematic literature search using Medline, Embase, and Cochrane Databases. The search, as outlined in the previous methodology paper,² was first conducted on November 25, 2019, which provided an update on all literature published since February 2013. A total of 2793 unique citations were identified. A single reviewer (NC) screened titles and abstracts against predetermined selection criteria and excluded ineligible publications. Full texts were independently assessed for inclusion by 2 reviewers (NC and LCC), with disagreements resolved through discussion. Reasons for exclusion at the full-text stage were recorded. This review resulted in a total of 50 studies reported across 101 articles. Data were extracted from the identified randomized controlled trials (RCT) by GRAPPA members and checked by a methodologist. A search update was conducted on August 28, 2020, which resulted in 175 unique citations, from which 19 articles were identified (15 RCT and 4 secondary papers from the RCT). In addition, a further 15 unpublished studies were identified from conference abstracts (n = 32) for consideration. This evidence is summarized, including effect sizes for main outcomes and a grading of evidence quality to translate into strong or weak recommendations.³ This created a library of extracted data to support recommendations within each domain group.

Guideline Development Process

GRAPPA committed, once again, to follow the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology in the development of these recommendations. In the treatment domain groups, the searches focused on RCT. However, due to a lack of data, additional searches were performed within the associated conditions and comorbidities groups to inform advice about comorbidity screening and how it may affect PsA treatment choice.

Each domain group has been involved in reviewing the extracted RCT data, running additional searches where required and synthesizing these data into domain recommendations.

Overarching Principles and Additional Guidance Statements

In the 2015 GRAPPA treatment recommendations, a set of overarching principles that will help guide the approach to therapy were included for the first time.¹ These were developed with both patient and clinician involvement. These will be reviewed for the 2020 recommendations based on any new evidence-based principles and experience-based approaches for goals of treatment. Additional statements are also proposed in the 2020 update to cover the topics of biosimilars and tapering therapies.² These are considered as general treatment principles rather than domain-specific issues. Both are important new developments in the field of PsA in recent years; these are particularly relevant to clinicians across the world. Specific position statements on both issues will be included in the final recommendations with input from the wider GRAPPA membership, including patient research partners.

Summary

It was clear that an update of the GRAPPA PsA treatment recommendations was necessary, linked to the significant advances in individual therapies and treatment approaches for PsA. This process has been undertaken throughout 2020 with some delays related to the worldwide COVID-19 (coronavirus disease 2019; caused by SARS-CoV-2) pandemic. Nevertheless, GRAPPA is currently finalizing domain-specific recommendations with an aim to produce updated treatment recommendations for publication in 2021.