Technology Appraisal Guidance No. 199
Source: National Institute for Health and Care Excellence
NOTE: This guidance replaces NICE technology appraisal guidance 104 issued in July 2006 and NICE technology appraisal guidance 125 issued in August 2007.
NICE reviews each piece of guidance it issues. This review and re-appraisal has resulted in an extension to the guidance:
- Etanercept, infliximab and adalimumab are all recommended for the treatment of active and progressive psoriatic arthritis, based on specific criteria. Treatment choice should be started with the least expensive drug (taking into account drug administration costs, required dose and product price per dose).
- The guidance recommends that treatment should be discontinued if people’s disease does not show an adequate response on the Psoriatic Arthritis Response Criteria (PsARC) at 12 weeks. Healthcare professionals should also consider continuing treatment if people’s skin disease has a Psoriasis Area and Severity Index (PASI) 75 response at 12 weeks in the absence of an adequate PsARC response. This assessment should be done by a dermatologist to determine whether continued treatment is
appropriate on the basis of the skin response alone.
1.1 Etanercept, infliximab and adalimumab are recommended for the treatment of adults with active and progressive psoriatic arthritis when the following criteria are met.
- The person has peripheral arthritis with three or more tender joints and three or more swollen joints, and
- The psoriatic arthritis has not responded to adequate trials of at least two standard disease-modifying antirheumatic drugs (DMARDs), administered either individually or in combination.
1.2 Treatment as described in 1.1 should normally be started with the least expensive drug (taking into account drug administration costs, required dose and product price per dose). This may need to be varied for individual patients because of differences in the method of administration and treatment schedules.
1.3 Etanercept, adalimumab or infliximab treatment should be discontinued in people whose psoriatic arthritis has not shown an adequate response using the Psoriatic Arthritis Response Criteria (PsARC) at 12 weeks. An adequate response is defined as an improvement in at least two of the four PsARC criteria, (one of which has to be joint tenderness or swelling score) with no worsening in any of the four criteria. People whose disease has a Psoriasis Area and Severity Index (PASI) 75 response at 12 weeks but whose PsARC response does not justify continuation of treatment should be assessed by a dermatologist to determine whether continuing treatment is appropriate on the basis of skin response (see ‘Etanercept and efalizumab for the treatment of adults with psoriasis’ [NICE technology appraisal guidance 103], ‘Infliximab for the treatment of adults with psoriasis’ [NICE technology appraisal guidance 134] and ‘Adalimumab for the treatment of adults with psoriasis’ [NICE technology appraisal guidance 146] for guidance on the use of tumour necrosis factor [TNF] inhibitors in psoriasis).
1.4 When using the PsARC healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect a person’s responses to components of the PsARC and make any adjustments they consider appropriate.
The guidance shown above constitutes Section 1 of the full document. A copy of the full document and a summary of the evidence is available on the Internet at http://guidance.nice.org.uk/TA199
An abridged version of this guidance (a 'quick reference guide') is also available. Printed copies of the quick reference guide can be obtained by contacting 0845 003 7783 or emailing email@example.com and quoting reference number N2278. It is also available on the Internet at http://guidance.nice.org.uk/TA199/QuickRefGuide/pdf/English.
This guidance represents the view of the Institute which was arrived at after careful consideration of the available evidence. Health professionals are expected to fully take it into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
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Enquiries concerning the guidance should be addressed to: National Institute for Health and Care Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA. email: firstname.lastname@example.org
Etanercept, Infliximab and Adalimumab for the Treatment of Psoriatic Arthritis.
Issue Date: August 2010
Review Date: June 2013