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rheum.psoriatic-arthritis.core.v1PRODUCTION
rheum.psoriatic-arthritis.core.v1

Psoriatic arthritis

rheumatologychronicadult
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12/12 authored

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Detailed

Adult chronic seronegative spondyloarthropathy across six domains — peripheral arthritis (asymmetric oligo / RA-like poly / DIP-predominant / arthritis mutilans), axial disease, enthesitis, dactylitis, skin psoriasis, nail disease — usually arising on a pre-existing psoriasis substrate (CASPAR; GRAPPA 2021; EULAR 2023)

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scope confirmed (PsA spectrum vs another spondyloarthropathy)

Patient inputs (15)

Skin/nail psoriasis usually precedes arthritis by ~10 yr; severity drives joint-vs-skin domain weighting and IL-17i/IL-23i selection (CASPAR; GRAPPA 2021)

Distinguishes asymmetric oligoarthritis / RA-like polyarthritis / DIP-predominant / arthritis mutilans peripheral domains (Moll-Wright; CASPAR)

Axial domain (inflammatory LBP, morning stiffness >30 min) — csDMARDs ineffective axially; needs TNFi/IL-17i/JAKi, NOT IL-23i (GRAPPA 2021; ASAS)

IBD association — AVOID IL-17 inhibitors (can flare/induce IBD); prefer anti-TNF monoclonal, IL-23i, or JAKi (GRAPPA 2021; EULAR 2023)

High burden of obesity, MetS, NAFLD, accelerated ASCVD and depression; weight loss improves treatment response and JAKi MACE/VTE risk weighting (EULAR 2023; GRAPPA 2021)

Dactylitis is a poor-prognosis marker and a treatable domain; favors TNFi/IL-17i (GRAPPA 2021; EULAR 2023)

Enthesitis-predominant disease responds poorly to MTX; drives early bDMARD/IL-17i/IL-23i/JAKi (GRAPPA 2021)

Elevated acute-phase reactants are a poor-prognosis marker and feed cDAPSA / DAS28-CRP surrogate activity (GRAPPA 2021; EULAR 2023)

Typically NEGATIVE (seronegative); positivity pivots toward RA and changes the differential (CASPAR awards points for RF-negative)

Latent TB (IGRA/PPD) and HBV/HCV screen mandatory before any biologic or JAKi (ACR/NPF 2021; GRAPPA 2021)

Peak onset 30–50 yr; informs differential (RA, OA, gout) and biologic/JAKi MACE-VTE risk weighting

Nail pitting/onycholysis is the strongest single skin association with PsA and predicts DIP/enthesitis disease (CASPAR)

Recurrent anterior uveitis favors anti-TNF monoclonal antibody over etanercept/IL-17i (GRAPPA 2021)

Existing MTX/biologic for skin may already cover joints; systemic steroid use risks pustular/erythrodermic psoriasis rebound on withdrawal (GRAPPA 2021)

Erosions with new bone formation, "pencil-in-cup", periostitis, sacroiliitis; arthritis mutilans = osteolysis/telescoping = severe (CASPAR; GRAPPA 2021)

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Severity triggers (6)

6 need judgement
  • informationallife_threateningerythrodermic_or_pustular_psoriasis_flare
    Erythrodermic or generalised pustular psoriasis flare — often precipitated by systemic corticosteroid withdrawal (GRAPPA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningserious_biologic_infection_or_tb_reactivation
    Sepsis / serious opportunistic infection / latent TB reactivation in a patient on bDMARD or JAKi (ACR/NPF 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverearthritis_mutilans_rapidly_destructive
    Arthritis mutilans / rapidly destructive polyarthritis — osteolysis, telescoping ("opera-glass") digits, pencil-in-cup on radiograph (GRAPPA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_anterior_uveitis
    Acute painful red eye, photophobia, blurred vision in a PsA/spondyloarthritis patient (GRAPPA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaxial_fragility_fracture
    Acute spinal pain / neurologic deficit in long-standing axial PsA — fragility/ankylosed-spine fracture risk (GRAPPA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatejaki_mace_vte_high_risk
    JAK inhibitor being considered/used in patient >65 yr, smoker, or high ASCVD/VTE risk (ACR/NPF 2021; EULAR 2023 boxed warning)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

PsA domain-driven treat-to-target ladder (cDAPSA / MDA)
axis: psa_domain_driven_treat_to_targetstep 0 - Step 0 — Domain triage + comorbidity mapping
Selected step "Step 0 — Domain triage + comorbidity mapping" — All PsA patients at diagnosis and at each escalation decision
  • six-domain assessment + cardiometabolic + IBD/uveitis screen
    first line
    clinical_assessment
    triggers: new_diagnosis, treatment_escalation_decision
    GRAPPA 2021 — therapy is selected by the dominant active domain (peripheral / axial / enthesitis / dactylitis / skin / nail) and comorbidity (IBD, uveitis, MetS, pregnancy); sets the treat-to-target goal (cDAPSA remission/LDA or MDA)
  • latent TB (IGRA/PPD) + HBV/HCV serology + vaccination update + age-appropriate malignancy screen
    first line
    pre_biologic_screen
    triggers: biologic_or_jaki_planned
    ACR/NPF 2021 — mandatory before any bDMARD/tsDMARD; treat latent TB before starting; complete inactivated vaccines, NO live vaccines once on biologic
  • weight loss + cardiometabolic risk modification (lipids, glucose, NAFLD, smoking, depression)
    add on
    lifestyle
    triggers: obesity, metabolic_syndrome, high_ascvd_risk
    EULAR 2023 — weight loss improves treatment response and CV outcomes; cardiometabolic burden is a defining PsA comorbidity

outpatient playbook — drug actions (5)

  1. 1. NSAID ± intra-articular steroid
    Naproxen 500 mg PO BID; triamcinolone 20–40 mg intra-articular • PO / intra-articular • BID / single
    trigger: Mild mono/oligoarthritis, no poor prognosis, no axial/enthesitis predominance
    GRAPPA 2021 — symptom control + early DMARD if persistent; avoid systemic steroid
  2. 2. methotrexate (csDMARD)
    15 mg PO/SC weekly titrate to 25 mg + folic acid 1 mg/d • PO/SC • weekly
    trigger: Peripheral oligo/polyarthritis, concomitant skin
    ACR/NPF 2021; GRAPPA 2021 — first csDMARD, also treats skin; leflunomide/sulfasalazine alternatives
  3. 3. bDMARD by dominant domain
    TNFi (adalimumab 40 mg SC q2wk) / IL-17i (secukinumab) / IL-23i (guselkumab) / IL-12-23 (ustekinumab) • SC • per agent
    trigger: csDMARD failure, poor prognosis, axial- or enthesitis-predominant; avoid IL-17i if IBD, anti-TNF mAb if uveitis, NOT IL-23i if axial-predominant
    GRAPPA 2021; EULAR 2023 — domain + comorbidity matched biologic
  4. 4. tsDMARD JAKi or PDE4i
    Tofacitinib 5 mg PO BID / upadacitinib 15 mg PO daily; apremilast 30 mg PO BID • PO • BID / daily
    trigger: bDMARD inadequate (JAKi) or milder/skin-predominant disease (apremilast); JAKi only if acceptable MACE/VTE/malignancy risk
    ACR/NPF 2021; EULAR 2023 — oral options; JAKi boxed warning caution
  5. 5. certolizumab (pregnancy-compatible TNFi)
    400 mg SC load then 200 mg SC q2wk • SC • q2 weeks
    trigger: Pregnancy or planning pregnancy needing active control
    EULAR 2023 — minimal placental transfer

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Inflammatory joint pain/swelling in a patient with cutaneous or nail psoriasis (CASPAR; GRAPPA 2021); Dactylitis ("sausage digit") or DIP-predominant arthritis (CASPAR; EULAR 2023); Enthesitis (Achilles/plantar fascia) or inflammatory back pain (axial PsA) (GRAPPA 2021; ASAS).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Psoriatic arthritis** (rheum.psoriatic-arthritis.core.v1).
Phenotype framing: Rheumatoid arthritis (RF/anti-CCP positive, symmetric, no DIP/dactylitis/nail/enthesitis/skin), axial spondyloarthritis (no psoriasis/nail, no peripheral PsA domain), osteoarthritis (DIP Heberden nodes, non-inflammatory), gout/CPPD (crystal — can co-exist), reactive arthritis, IBD-associated arthritis (CASPAR; GRAPPA 2021)
Scope: Adult chronic seronegative spondyloarthropathy across six domains — peripheral arthritis (asymmetric oligo / RA-like poly / DIP-predominant / arthritis mutilans), axial disease, enthesitis, dactylitis, skin psoriasis, nail disease — usually arising on a pre-existing psoriasis substrate (CASPAR; GRAPPA 2021; EULAR 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **PsA domain-driven treat-to-target ladder (cDAPSA / MDA)** — step "Step 0 — Domain triage + comorbidity mapping".
1. six-domain assessment + cardiometabolic + IBD/uveitis screen (clinical_assessment, first line) — GRAPPA 2021 — therapy is selected by the dominant active domain (peripheral / axial / enthesitis / dactylitis / skin / nail) and comorbidity (IBD, uveitis, MetS, pregnancy); sets the treat-to-target goal (cDAPSA remission/LDA or MDA)
2. latent TB (IGRA/PPD) + HBV/HCV serology + vaccination update + age-appropriate malignancy screen (pre_biologic_screen, first line) — ACR/NPF 2021 — mandatory before any bDMARD/tsDMARD; treat latent TB before starting; complete inactivated vaccines, NO live vaccines once on biologic
3. weight loss + cardiometabolic risk modification (lipids, glucose, NAFLD, smoking, depression) (lifestyle, add on) — EULAR 2023 — weight loss improves treatment response and CV outcomes; cardiometabolic burden is a defining PsA comorbidity

Setting playbook (outpatient) — Confirm PsA (CASPAR), map the six domains, start domain-matched treat-to-target therapy (cDAPSA/MDA), screen + clear safety before biologic, co-manage skin with dermatology and cardiometabolic risk (GRAPPA 2021; ACR/NPF 2021; EULAR 2023)
4. NSAID ± intra-articular steroid Naproxen 500 mg PO BID; triamcinolone 20–40 mg intra-articular PO / intra-articular BID / single — Mild mono/oligoarthritis, no poor prognosis, no axial/enthesitis predominance (GRAPPA 2021 — symptom control + early DMARD if persistent; avoid systemic steroid)
5. methotrexate (csDMARD) 15 mg PO/SC weekly titrate to 25 mg + folic acid 1 mg/d PO/SC weekly — Peripheral oligo/polyarthritis, concomitant skin (ACR/NPF 2021; GRAPPA 2021 — first csDMARD, also treats skin; leflunomide/sulfasalazine alternatives)
6. bDMARD by dominant domain TNFi (adalimumab 40 mg SC q2wk) / IL-17i (secukinumab) / IL-23i (guselkumab) / IL-12-23 (ustekinumab) SC per agent — csDMARD failure, poor prognosis, axial- or enthesitis-predominant; avoid IL-17i if IBD, anti-TNF mAb if uveitis, NOT IL-23i if axial-predominant (GRAPPA 2021; EULAR 2023 — domain + comorbidity matched biologic)
7. tsDMARD JAKi or PDE4i Tofacitinib 5 mg PO BID / upadacitinib 15 mg PO daily; apremilast 30 mg PO BID PO BID / daily — bDMARD inadequate (JAKi) or milder/skin-predominant disease (apremilast); JAKi only if acceptable MACE/VTE/malignancy risk (ACR/NPF 2021; EULAR 2023 — oral options; JAKi boxed warning caution)
8. certolizumab (pregnancy-compatible TNFi) 400 mg SC load then 200 mg SC q2wk SC q2 weeks — Pregnancy or planning pregnancy needing active control (EULAR 2023 — minimal placental transfer)

Non-pharmacologic actions:
- Dermatology co-management of skin/nail domain (GRAPPA 2021)
- Physical therapy / structured exercise for axial + enthesitis (EULAR 2023)
- Weight loss + cardiometabolic risk reduction (improves response) (EULAR 2023)
- Vaccination update before biologic; no live vaccines on biologic (ACR/NPF 2021)
- Treat latent TB before biologic; monitor HBV on therapy (ACR/NPF 2021)
- Smoking cessation + depression management (EULAR 2023)

AVOID / contraindication checks:
- Avoid systemic corticosteroid psoriasis rebound pustular erythrodermic on taper (GRAPPA 2021)
- Avoid IL17 inhibitor in active or history of IBD (GRAPPA 2021; EULAR 2023)
- JAK inhibitor boxed MACE VTE malignancy serious infection caution age>65 smoker high CV risk (ACR/NPF 2021; EULAR 2023)
- No biologic or JAKi with untreated latent TB or active HBV (ACR/NPF 2021; GRAPPA 2021)
- No live vaccines while on biologic or JAKi (ACR/NPF 2021)
- Avoid IL23 and IL12/23 as monotherapy for axial predominant disease no proven axial efficacy (GRAPPA 2021)
- Methotrexate leflunomide teratogenic effective contraception and washout before pregnancy (EULAR 2023)
- Exclude septic arthritis before escalating immunomodulation in acute hot joint (GRAPPA 2021)

Monitoring

Regimen monitoring:
- cDAPSA/MDA q1-3mo until target then q3-6mo (GRAPPA 2021; EULAR 2023 treat-to-target)
- MTX CBC+LFT+creatinine q2-4wk during titration then q8-12wk (ACR/NPF 2021)
- leflunomide LFT+BP periodic; sulfasalazine CBC+LFT periodic (GRAPPA 2021)
- lipids on JAK inhibitor (and IL-6 pathway agents if used) (EULAR 2023)
- periodic latent-TB reassessment + HBV monitoring on biologic (ACR/NPF 2021)
- annual cardiometabolic review (lipids, A1c, BMI, NAFLD) + depression screen (EULAR 2023)
- skin/nail + entheseal + axial mobility exam each visit (GRAPPA 2021)

Setting (outpatient) monitoring:
- cDAPSA/MDA q1-3mo until target then q3-6mo (GRAPPA 2021)
- MTX CBC/LFT/creatinine q2-4wk titration then q8-12wk (ACR/NPF 2021)
- Lipids on JAKi; periodic TB/HBV reassessment on biologic (EULAR 2023; ACR/NPF 2021)
- Annual cardiometabolic + depression review (EULAR 2023)

Follow-up plan: Long-term DMARD/biologic continuation with periodic taper consideration at sustained remission; lifelong cardiometabolic risk modification (weight, lipids, glucose, smoking), depression management, dermatology co-care, physical therapy for enthesitis/axial mobility, vaccination upkeep, orthopedic referral for arthritis mutilans / fixed deformity (GRAPPA 2021; EULAR 2023)
- Close-out criterion: long-term multidisciplinary plan + patient education + return precautions complete

Monitoring phase: cDAPSA / MDA every 1–3 months until target then every 3–6 months (treat-to-target). MTX: CBC + LFT + creatinine q2–4 wk during titration then q8–12 wk; leflunomide LFT/BP; sulfasalazine CBC/LFT. Lipids on JAKi (and IL-6 if used). Periodic latent-TB reassessment, HBV monitoring on biologic. Annual cardiometabolic review (lipids, A1c, BMI, NAFLD), depression screening, skin/nail and entheseal exam (GRAPPA 2021; EULAR 2023; ACR/NPF 2021)

Disposition

Current setting: outpatient — Confirm PsA (CASPAR), map the six domains, start domain-matched treat-to-target therapy (cDAPSA/MDA), screen + clear safety before biologic, co-manage skin with dermatology and cardiometabolic risk (GRAPPA 2021; ACR/NPF 2021; EULAR 2023)

Disposition criteria:
- Continue outpatient rheumatology + dermatology co-care; treat-to-target titration (GRAPPA 2021)
- Refer/admit for emergent uveitis, erythrodermic/pustular psoriasis, serious biologic infection, or surgical mutilans (EULAR 2023)

Escalation triggers (move to higher acuity):
- Acute painful red eye / photophobia → emergent ophthalmology (uveitis) (GRAPPA 2021)
- Erythrodermic or generalised pustular psoriasis flare → urgent dermatology / admission (GRAPPA 2021)
- Serious infection or TB reactivation on biologic/JAKi → hold therapy + ID (ACR/NPF 2021)
- Rapidly destructive polyarthritis / arthritis mutilans → expedite escalation + orthopedics (GRAPPA 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Erythrodermic or generalised pustular psoriasis flare — often precipitated by systemic corticosteroid withdrawal (GRAPPA 2021)
- [LIFE_THREATENING] Sepsis / serious opportunistic infection / latent TB reactivation in a patient on bDMARD or JAKi (ACR/NPF 2021)
- [SEVERE] Arthritis mutilans / rapidly destructive polyarthritis — osteolysis, telescoping ("opera-glass") digits, pencil-in-cup on radiograph (GRAPPA 2021)

Citations

- 2021 ACR/NPF PsA Guideline + 2023 EULAR PsA recommendations + GRAPPA 2021 + CASPAR criteria [PMID:30499246](https://pubmed.ncbi.nlm.nih.gov/30499246/)
- Cited evidence (PMID 38499325) [PMID:38499325](https://pubmed.ncbi.nlm.nih.gov/38499325/)
- Cited evidence (PMID 35761070) [PMID:35761070](https://pubmed.ncbi.nlm.nih.gov/35761070/)
- Cited evidence (PMID 16871531) [PMID:16871531](https://pubmed.ncbi.nlm.nih.gov/16871531/)
- Cited evidence (PMID 26433318) [PMID:26433318](https://pubmed.ncbi.nlm.nih.gov/26433318/)

Last reconciled with current guidelines: 2026-05-22.
References