Table 3 Comparison of complex-to-manage psoriatic arthritis and treatment-refractory psoriatic arthritis

From: Consensus definitions of complex-to-manage and treatment-refractory psoriatic arthritis: a GRAPPA initiative

Aspect

C2M-PsA

TR-PsA

Treatment exposure

Failure of ≥ 1 b/tsDMARD (≥ 12 weeks or earlier if the patient has adverse events or intolerance)

Failure to respond to ≥ 3 MoAs including ≥ 2 b/tsDMARDs; adverse events or intolerance not counted; adequate dose, interval and duration

Persistent symptoms

Composite or domain-specific activity present

Composite or domain-specific activity present

Perceived as problematic

Either patient or clinician threshold positive

Both patient and clinician thresholds positive at the same visit

Objective inflammation

Not required, although can be presenta

Required: (a) clinical, (b) laboratory, (c) imaging, (d) synovial fluid or (e) active associated conditions

Alternative explanations evaluated

Not mandatory

TR-PsA classification if PsA activity is the primary driver of disease manifestations

Exclusion should only occur when another condition better explains the clinical pictureb

Pillarsc required

Pillars 1–3

Pillars 1–5

  1. bDMARDs; biologic DMARDs; C2M-PsA, complex-to-manage psoriatic arthritis; MoAs, mechanisms of action; TR-PsA, treatment-refractory psoriatic arthritis; tsDMARDs, targeted synthetic DMARDs. aDocument contextual drivers if absent. bExclusions refer only to cases where another condition better explains the clinical picture (e.g., pure mechanical OA, infections, gout flare with monosodium urate crystals). Coexisting conditions do not preclude classification of TR-PsA if PsA activity is present. cPillar 1: treatment exposure; pillar 2: persistent symptoms; pillar 3: perceived as problematic; pillar 4: objective inflammation; pillar 5: exclusion of an alternative explanation as the main driver of systemic inflammation.
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