Diagnosis and therapeutic management of psoriatic arthritis: summary of 2024 update of the Spanish clinical practice guideline (ESPOGUIA)

Abstract

Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory disease affecting peripheral and axial joints, entheses, skin, and nails, requiring coordinated multidisciplinary management. Since the 2018 edition of ESPOGUÍA, significant advances—including the availability of IL-17A/F, IL-23, and JAK inhibitors, as well as emerging evidence regarding axial PsA—have prompted the need for an updated guideline. The 2024 ESPOGUÍA provides evidence-based recommendations for the diagnosis and management of PsA, integrating multidisciplinary collaboration, active nursing participation, lifestyle counseling, and specific considerations for axial disease. A panel comprising rheumatologists, dermatologists, gastroenterologists, ophthalmologists, nurses, methodologists, and patient representatives formulated clinical questions using the Population, Intervention, Comparator, and Outcomes (PICO) framework. Systematic literature reviews were performed, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was applied to critically assess the quality of evidence and guide the formulation of recommendations. The guideline emphasizes early intervention and the appropriate use of conventional synthetic DMARDs, biologic therapies, and JAK inhibitors across different disease domains, including the management of extra-musculoskeletal manifestations. Lifestyle measures, such as smoking cessation and weight management, are highlighted due to their demonstrated impact on disease activity and long-term outcomes. The essential role of specialized rheumatology nurses in patient education, treatment adherence, and counseling on modifiable risk factors is also underscored. ESPOGUÍA 2024 provides a comprehensive, multidisciplinary, and patient-centered framework for PsA management, including axial involvement, and identifies persistent gaps in early diagnosis, biomarker development, and long-term outcomes, thereby outlining priorities for future research

Plain language summary

Diagnosing and Treating Psoriatic Arthritis: Highlights from the 2024 Spanish Clinical Guidelines

Psoriatic arthritis (PsA) is a long-term inflammatory disease that can affect the joints, spine, skin, nails, and enthesis. Symptoms and disease severity vary widely, so many people with PsA need care from several healthcare professionals working together.

Since the last Spanish clinical guideline was published in 2018, major advances have been made in PsA treatment. New targeted medicines are now available, and there is better understanding of PsA that affects the spine (axial PsA). These changes led to an update of the guideline.

The 2024 ESPOGUÍA guideline provides clear, evidence-based recommendations for diagnosing and managing PsA. It emphasizes multidisciplinary care, including the important role of nurses, and highlights the value of healthy lifestyle habits such as stopping smoking and maintaining a healthy weight. The guideline also includes specific advice for people with spinal involvement.

A multidisciplinary group of doctors, nurses, researchers, and patient representatives developed the guideline using internationally accepted methods. They reviewed the best available scientific evidence and assessed its quality before making recommendations.

The updated recommendations focus on early diagnosis and timely treatment to reduce symptoms and prevent long-term damage. They cover the use of conventional treatments, biological therapies, and newer targeted drugs, depending on individual disease features. Conditions affecting organs beyond the joints are also addressed. Specialized rheumatology nurses are recognized as key members of the care team, supporting patient education, treatment adherence, and lifestyle counselling.

Overall, ESPOGUÍA 2024 offers a comprehensive, patient-centred approach to psoriatic arthritis care and identifies priorities for future research, including earlier diagnosis and better long-term outcomes.

Introduction

Psoriatic arthritis (PsA) is a chronic inflammatory disease that significantly impacts patients’ quality of life. ¹ This condition can involve the peripheral joints, axial skeleton (sacroiliac joints and spine), entheses, tendon sheaths (causing dactylitis), skin, nails, and extra-articular organs like the gut and eyes. ¹ The clinical heterogeneity and wide range of musculoskeletal and extra-musculoskeletal manifestations make diagnosis and management complex, often requiring close collaboration between rheumatologists and other healthcare professionals.^2,3

To address the variability in clinical practice and improve outcomes for PsA patients, the Spanish Society of Rheumatology (SER) has led the development and update of ESPOGUÍA, a Clinical Practice Guideline (CPG). ⁴ This document follows earlier versions published in 2009, 2015, and 2018. ESPOGUÍA is a structured set of evidence-based recommendations designed to optimize patient care through systematic literature reviews and risk–benefit assessments of available treatment options. ⁴

Significant therapeutic advances since the 2018 version prompted the creation of this updated guideline. Notable developments include the approval of new biologic therapies for PsA (such as IL-23 and IL-17A/F inhibitors) and JAK inhibitors. ³ New evidence supports the efficacy and safety of IL-17A inhibitors in axial PsA, while head-to-head trials comparing IL-17A and TNF-alpha inhibitors have provided important comparative data.^5,6 In addition, methotrexate has shown potential benefits in treating PsA-related enthesitis and dactylitis. ⁷ Retrospective studies also suggest that early biologic treatment for psoriasis may delay or prevent the onset of PsA. ⁸ The ongoing debate about whether axial spondyloarthritis (axSpA) and axial PsA (axPsA) represent the same disease is also addressed in this update.^2,3

ESPOGUÍA was developed by a broad, multidisciplinary group of healthcare professionals from across Spain involved in the management of PsA patients. ⁴

The primary goal of this guideline is to support rheumatologists and other healthcare professionals in making evidence-based decisions about therapeutic interventions for adults with PsA. When evidence is limited, recommendations are based on expert consensus.^3,4

Specific objectives include improving the clinical skills of healthcare professionals, reducing variability in treatment approaches, evaluating the efficacy, safety, and effectiveness of available therapies, promoting collaboration across specialties—especially between dermatologists and rheumatologists—and providing accessible information to patients and families to empower them in understanding and managing these conditions. ⁴

The target users of this guideline include not only rheumatologists but also dermatologists, gastroenterologists, ophthalmologists, physiotherapists, nurses, primary care physicians, and patients themselves. The overarching aim is to support integrated, coordinated, and patient-centered care based on current scientific evidence. ⁴

Methodology of guideline development

The development of the ESPOGUÍA CPG followed a structured and rigorous methodology to ensure the reliability and relevance of its recommendations. The process was led by the Spanish Society of Rheumatology (SER) and aligned with international standards for guideline development.^9–12

A multidisciplinary panel was formed, including rheumatologists, dermatologists, gastroenterologists, ophthalmologists, nurses, patients, and methodologists. These professionals were selected in a competitive call based on their clinical experience, research background, and involvement in the management of patients with PsA. Their collaboration ensured a comprehensive approach that reflects the complexity of the psoriatic disease.

To guide the literature review and recommendation process, the working group formulated clinical questions using the PICO model (Population, Intervention, Comparison, Outcome). These structured questions helped identify the most relevant issues related to diagnosis, treatment, and patient management. Each question focused on evaluating the efficacy, safety, and applicability of various pharmacological and non-pharmacological interventions.^9–11

A systematic review of the scientific literature was then conducted for each PICO question up to the end of August 2023. During the final drafting process, additional relevant studies published in 2024 were reviewed and incorporated when deemed clinically significant by the panel. High-quality databases (Medline (through PubMed), Embase (Elsevier), Cochrane Library (Wiley Online Library), and the Cumulative Index to Nursing & Allied Health Literature (EBSCOhost)) were used to retrieve clinical trials, observational studies, and systematic reviews, focusing on recent publications and evidence relevant to the Spanish healthcare context. When no direct evidence was available, indirect or lower-level evidence was considered, always with transparency regarding limitations (Table 1).^9–11

Table 1.

ESPOGUIA recommendations.

Recommendation 1: For patients with peripheral PsA and poor prognostic factors (polyarthritis, structural damage, elevated CRP, dactylitis, or nail disease), early treatment with synthetic and/or biologic DMARDs is suggested to improve symptoms, function, and quality of life by suppressing inflammation. (Weak recommendation in favor)

Recommendation 2: In active PsA, after failure or intolerance to conventional synthetic or biologic DMARDs, IL-17 and JAK inhibitors are recommended for peripheral, axial, enthesitis, and dactylitis manifestations. (Strong recommendation)

Recommendation 3: IL-23 inhibitors are recommended for peripheral disease, enthesitis, and dactylitis. (Strong recommendation)

Recommendation 4: IL-17, IL-23, and JAK inhibitors are recommended to prevent structural damage. (Strong recommendation)

Recommendation 5: Apremilast may be considered for peripheral PsA, enthesitis, and dactylitis after failure of conventional therapy. (Weak recommendation)

Recommendation 6: In PsA patients who fail conventional synthetic DMARDs, any biologic (TNF, IL-17, IL-23, IL-12/23) or JAK inhibitor is recommended. (Strong recommendation)

Recommendation 7: csDMARDs (methotrexate, leflunomide, sulfasalazine) are the first line for active peripheral PsA. (Strong recommendation). Methotrexate is the preferred option. (Weak recommendation)

Recommendation 8: csDMARDs are not recommended for axial symptoms. (Weak recommendation)

Recommendation 9: Biologic or targeted synthetic drugs can be used alone or in combination with csDMARDs for peripheral PsA. (Strong recommendation)

Recommendation 10: Combining methotrexate with TNF inhibitors, especially infliximab, may enhance drug survival. (Weak recommendation)

Recommendations 11: TNF, IL-17, or IL-23 inhibitors are recommended for psoriasis in PsA patients. (Strong recommendation)

Recommendation 12: In moderate-to-severe psoriasis, IL-17, IL-12/23, or IL-23 inhibitors are preferred over TNF inhibitors. (Good clinical practice)

Recommendation 13: JAK inhibitors may be considered in active psoriasis; collaboration with dermatology is advised. (Good clinical practice)

Recommendation 14: Apremilast may be considered for mild psoriasis. (Good clinical practice)

Recommendation 15: Abatacept is not recommended for psoriasis in PsA. (Strong recommendation against)

Recommendation 16: For patients with PsA and active inflammatory bowel disease (IBD), monoclonal TNF inhibitors (infliximab, adalimumab), IL-12/23, IL-23 (risankizumab for ulcerative colitis and Crohn’s disease), or JAK inhibitors (tofacitinib for ulcerative colitis), upadacitinib (for ulcerative colitis and Crohn’s disease) are recommended. (Strong recommendation)

Recommendation 17: IL-17 inhibitors are not recommended in patients with PsA and IBD. (Strong recommendation against)

Recommendation 18: Due to limited evidence in PsA-related uveitis, refer to axial spondyloarthritis guidelines. (Good clinical practice)

Recommendation 19: PsA patients should stop smoking and maintain a BMI under 25 to improve disease control. (Strong recommendation)

Recommendation 20: Involvement of specialized rheumatology nurses (in-person or via phone) can improve patient satisfaction. (Weak recommendation)

Recommendation 21: Smoking cessation programs led by nurses may increase quit rates. (Weak recommendation)

Recommendation 22: Nurse-led educational workshops can ease fears about subcutaneous therapies. (Weak recommendation)

Recommendation 23: Nurses may assist with self-assessment questionnaires, without influencing patient preferences. (Weak recommendation)

Recommendation 24: Group education programs by trained nurses may promote self-management and treatment adherence. (Weak recommendation)

PsA, Psoriatic arthritis

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was applied to assess the quality of evidence and determine the strength of each recommendation. This widely recognized methodology considers factors such as study design, consistency of results, directness of evidence, and risk of bias. Recommendations were classified as strong or conditional, depending on the balance between benefits and harms, patients’ values and preferences, and resource implications.^9–11

GRADE allowed the panel to make recommendations, clearly indicating the confidence in the evidence and the rationale behind each decision. Where evidence was limited, expert consensus was used, following a structured discussion and voting process. ¹²

Inclusion of the patient perspective was a key component of the guideline development. Patient representatives participated in the process, helping to ensure that recommendations address real-world concerns and priorities. Their input was especially valuable in defining outcomes important to patients and in shaping recommendations around quality of life and communication in health care. ¹²

Finally, a public consultation process was conducted, where a draft of the guideline was made available for feedback from health professionals, patients, and other stakeholders. This phase allowed for external review, transparency, and broader consensus before the final version was published. ¹¹

Clinical topics addressed in ESPOGUIA

Early pharmacological intervention

Since PsA is a chronic inflammatory disease that can lead to joint destruction, impairing functional capacity and quality of life, it is important to identify predictors of poor prognosis in the first visits, since these may influence decisions concerning treatment. In cohorts of patients with a short history of the disease (⩽ 2 years), joint erosions have been identified in nearly 50% of cases. Bone erosion and other signs of joint damage are closely associated with reductions in functional capacity and poor overall prognosis.^13,14 Although the evidence found does not come from RCTs, early pharmacological intervention, and possibly also tight control with treat-to-target strategies, may improve clinical prognosis in patients with PsA. ¹⁵ On the other hand, aggressive tight control strategies may be associated with a higher incidence of adverse events. ¹⁵ Early pharmacological intervention may prevent structural damage, thereby maintaining functional capacity and quality of life in patients with PsA. ¹⁶ Thus, for patients with peripheral PsA and poor prognostic factors (polyarthritis, structural damage, elevated CRP, dactylitis, or nail disease), early treatment with synthetic and/or biologic DMARDs is suggested to improve symptoms, function, and quality of life by suppressing inflammation. ³

Efficacy of csDMARDs in axial and peripheral disease, enthesitis, and dactylitis

Although no high-quality evidence coming from clinical trials has shown definitive efficacy of MTX in PsA, the panel of experts recommended the use of csDMARDs (MTX, LFN, and SSZ) as the first-line treatment in patients with active peripheral PsA. Among csDMARDs, MTX is considered the treatment of choice, given its effects on arthritis and psoriasis. New evidence coming from TICOPA ¹⁵ and SEAM ⁷ trials and the broad good clinical experience in clinical practice supported these recommendations. On the contrary, the use of csDMARDs was not recommended for treating axial disease.

Efficacy of IL-17, IL-23, JAK inhibitors, and apremilast

Based on the results of double-blind placebo-controlled RCTs, IL-17 and JAK inhibitors are recommended for peripheral, axial, enthesitis, and dactylitis manifestations in active PsA after failure or intolerance to conventional synthetic or biologic DMARDs. IL-23 inhibitors are recommended for peripheral disease, enthesitis, and dactylitis. IL-17, IL-23, and JAK inhibitors are recommended to prevent structural damage. Although not all IL-23 inhibitor trial arms showed slowed structural damage (only guselkumab has currently demonstrated an effect on slowering radiographic progression), the panel believes these drugs have a clinically meaningful effect, and that small sample sizes and strong placebo responses likely limited the results.

Although to date, no consensus has been reached on the definition of axPsA, the direct evidence shown in MAXIMISE study for Secukinumab (SEC) ¹⁷ and indirect evidence from the approval of all IL17 and JAK inhibitors for axSpA suggest they may have efficacy in axPsA. On the other hand, there is even less evidence regarding IL-23 inhibitors in this domain. Although the STAR trial is underway, and post hoc analyses have already been published suggesting the efficacy of IL-23 inhibitors in axPsA, ¹⁸ the current lack of RCT data, together with the negative results concerning the efficacy of these drugs in axSpA, ¹⁹ lead the panel to defer making any recommendations on the use of IL-23 inhibitors in axPsA until more evidence is available.

Finally, due to the modest results from PALACE trials, apremilast may be considered for peripheral PsA, enthesitis, and dactylitis after failure of conventional therapy, but not for axial disease.

Comparison between IL and JAK inhibitors and TNF inhibitors

Based on the results of studies on TNF, IL-17, IL-23, IL-12/23, or JAK inhibitors, the efficacy/effectiveness of the various biological therapies in PsA is similar, without robust evidence of the superiority of any one target over another. Therapies targeting IL-17 and IL-23 only appear to be superior to TNF inhibitors for treating skin disease in PsA, obtaining similar results for the musculoskeletal domain (arthritis, enthesitis, and dactylitis). JAK inhibitors perform similarly to drugs with other targets, but the safety issues with these drugs, which affect certain subgroups described above, suggest their use after biological therapies. Therefore, in PsA patients who fail conventional synthetic DMARDs, any biologic (TNF, IL-17, IL-23, IL-12/23) or JAK inhibitor is recommended, given that there is no evidence that there is a significant difference between them in terms of efficacy, effectiveness, or safety, apart from a difference in efficacy in treating extra-musculoskeletal manifestations. This is in line with the recent 2023 EULAR guidelines for the management of PsA. ³

Combination therapy

The superiority of TNF inhibitors combined with methotrexate over TNF inhibitor monotherapy has been clearly demonstrated in rheumatoid arthritis, particularly in the ATTRACT and PREMIER trials.^20,21 Although PsA differs pathophysiologically from RA, combination therapy has been explored in this context.

In the SEAM-PsA trial, etanercept monotherapy showed similar efficacy to combination therapy with methotrexate, suggesting limited additional benefit of MTX in peripheral PsA. ⁷ Nevertheless, real-world data indicate that concomitant methotrexate may reduce immunogenicity and improve drug survival, particularly with monoclonal TNF inhibitors such as infliximab and adalimumab. ²²

Current EULAR (2023) and GRAPPA (2021) recommendations do not mandate long-term combination therapy in PsA, but allow its use based on individual patient characteristics and therapeutic goals.^2,3

Therefore, the panel concluded that bDMARDs or targeted synthetic DMARDs may be used as monotherapy or in combination with csDMARDs in peripheral PsA. Combining methotrexate with monoclonal TNF inhibitors, especially infliximab, may enhance drug survival in selected patients.

Effectiveness of treatments in extra-musculoskeletal manifestations

PsA may be associated with extra-musculoskeletal manifestations including inflammatory bowel disease (IBD), uveitis, and psoriasis. Monoclonal TNF inhibitors (infliximab and adalimumab) have demonstrated efficacy across these domains, particularly in IBD and uveitis.^23,24 IL-12/23 and IL-23 inhibitors, such as ustekinumab and risankizumab, have proven efficacy in Crohn’s disease and ulcerative colitis, ²⁵ and may therefore be preferred when IBD coexists with PsA. JAK inhibitors (tofacitinib and upadacitinib) have demonstrated efficacy in ulcerative colitis and Crohn’s disease in large randomized trials. ²⁵ Conversely, IL-17 inhibitors are not recommended in patients with concomitant IBD due to negative results and potential exacerbation of intestinal inflammation observed in clinical trials. ²⁶ In psoriasis, IL-17 and IL-23 inhibitors have consistently demonstrated superior skin efficacy compared with TNF inhibitors in head-to-head trials. ²⁷

Impact of smoking and obesity on disease outcomes

Smoking and obesity are prevalent in PsA and associated with worse disease outcomes and reduced treatment response. ²⁸ Lifestyle modifications are important components of comprehensive management and align with EULAR 2021 guidelines on lifestyle and rheumatic diseases. ²⁸ Therefore, PsA patients should stop smoking and maintain a body mass index (BMI) under 25 to improve disease control. Regarding obesity, there is a causal link with PsA, while the link is less clear for smoking. Regardless of the potential link, both obesity and smoking are modifiable factors that should be included in a comprehensive approach to managing this psoriatic disease. These patients should be offered referral to smoking cessation or weight management services or their general practitioner, to receive information about such services.

Nurse-led education in PsA patients

Patients with axSpA or PsA with peripheral and/or axial involvement have chronic inflammatory processes that tend to cause pain and functional disability, which may lead to the development of mood disorders such as anxiety and depression. All this has a negative impact on their family, social, and work lives. There is consensus that health professionals should provide comprehensive and multidisciplinary care, in which nurses play a key role in delivering educational programs for patients and their families. This includes all structured activities that seek to enhance patient knowledge of topics related to their condition at the individual, group, and community levels. ²⁹ Specifically, rheumatology nurses can contribute to educational programs for patients that help them manage their condition and the associated comorbidities. The key components of such patient education programs are the provision of information and training of patients about the diagnostic procedures used for their condition, treatments, exercise, pain management, and joint care.^30–34

Involvement of specialized rheumatology nurses (in-person or via phone) can improve patient satisfaction. Smoking cessation programs led by nurses may increase quit rates. Nurse-led educational workshops can ease fears about subcutaneous therapies. Nurses may assist with self-assessment questionnaires, without influencing patient preferences. Group education programs by trained nurses may promote self-management and treatment adherence.

Cross-cutting and multidisciplinary aspects

The management of PsA requires an integrative, patient-centered approach that goes beyond the scope of rheumatology alone. This condition often present extra-musculoskeletal manifestations (including cutaneous, ocular, and gastrointestinal involvement) that necessitate close collaboration with dermatology, ophthalmology, and gastroenterology to ensure comprehensive and continuous care. Such multidisciplinary coordination not only minimizes fragmentation of care but also facilitates early detection and appropriate treatment of co-morbid conditions. ³⁵

Specialized nursing plays a pivotal role in this setting. Educational programs, either delivered in person or remotely, have been shown to improve treatment adherence, support self-management, and enhance patient satisfaction. Initiatives such as patient schools or structured “expert patient” programs are increasingly recognized as valuable tools to improve quality of life and to empower patients in the long-term management of their disease. ³⁶

A further cross-cutting dimension is the promotion of shared decision-making. Incorporating patient-reported outcomes (PROs) into routine practice ensures that aspects such as fatigue, psychological distress, or social participation are systematically considered. ³⁷ This fosters a more bidirectional physician–patient relationship and aligns therapeutic strategies with individual preferences and life priorities.

Taken together, the ESPOGUÍA 2024 emphasizes that effective management of PsA requires a broad perspective, integrating multidisciplinary teamwork, structured patient education, and person-centered care models. This shift highlights the importance of treating not only the inflammatory burden but also the overall impact of disease on patients’ lives.

Future research

The ESPOGUÍA 2024 highlights several research priorities that remain unresolved, and which should guide the scientific agenda in the coming years. One central challenge is to better delineate the overlap and differences between axial PsA and axSpA, including the development of more specific classification and diagnostic criteria at very early stages. ³⁸ Closely linked to this is the need for validated biomarkers—serological, imaging, and molecular—that can predict disease onset, progression, or therapeutic response. Early identification of psoriasis patients at risk of transition to PsA is particularly relevant in this regard. ³⁹

Therapeutic optimization is another critical area. While b/tsDMARDs have transformed outcomes, there is limited evidence on dose tapering, drug survival, and long-term cost-effectiveness in patients achieving sustained remission. Head-to-head comparative studies between different modes of action remain scarce, and robust data are needed to guide personalized treatment decisions. ⁴⁰

Beyond pharmacology, the guideline calls for studies exploring the impact of structured exercise programs in advanced disease, the role of educational and nurse-led interventions in improving adherence, and the long-term consequences of lifestyle factors such as smoking and obesity. ²⁸ Furthermore, advances in microbiome research and multi-omics technologies applied to synovial and entheseal tissues may provide new mechanistic insights and novel therapeutic targets. ⁴⁰

Conclusion

The 2024 update of the Spanish CPG for psoriatic arthritis (ESPOGUÍA) constitutes an important step forward in the evidence-based management of this disease. By incorporating recent therapeutic advances and formulating structured, context-specific recommendations, the guideline provides a comprehensive framework to support clinical decision-making.

The document emphasizes the importance of an integrated treatment strategy that combines pharmacological and non-pharmacological interventions, is coordinated across relevant specialties, and is tailored to individual patient characteristics. It further underscores shared decision-making and the systematic assessment of PROs as key components of contemporary clinical practice.

Despite these advances, several unmet needs remain. Persistent gaps include early diagnosis, identification, and validation of biomarkers, and long-term therapeutic optimization, particularly with respect to treatment tapering strategies and sustainability in real-world settings. Addressing these challenges through coordinated and multidisciplinary research initiatives will be critical to improving long-term outcomes.

In summary, ESPOGUÍA 2024 not only updates therapeutic recommendations but also proposes a comprehensive and patient-centered model for psoriatic arthritis management. Future efforts should focus on broad dissemination and effective implementation in routine clinical practice to promote more consistent, equitable, and high-quality care.