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 3 or more tender joints and 3 or more swollen joints and
the psoriatic arthritis has not responded to adequate trials of at least 2 standard disease-modifying antirheumatic drugs (DMARDs), administered either individually or in combination.
Treatment as described in recommendation 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.
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 2 of the 4 criteria in PsARC (1 of which has to be joint tenderness or swelling score) with no worsening in any of the 4 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 NICE's technology appraisal guidance on etanercept and efalizumab, infliximab and adalimumab for guidance on the use of tumour necrosis factor [TNF] inhibitors in psoriasis).
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.