1.1 Upadacitinib, alone or with methotrexate, is recommended as an option for treating active psoriatic arthritis in adults whose disease has not responded well enough to disease-modifying antirheumatic drugs (DMARDs) or who cannot tolerate them. It is recommended only if they have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints and:
they have had 2 conventional DMARDs and at least 1 biological DMARD or
TNF-alpha inhibitors are contraindicated but would otherwise be considered (as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis).
Upadacitinib is recommended only if the company provides it according to the commercial arrangement.
1.2 Assess the response to upadacitinib after 12 weeks of treatment. Only continue treatment if there is clear evidence of response. This is defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria. If PsARC response does not justify continuing treatment but there is a Psoriasis Area and Severity Index (PASI) 75 response, a dermatologist should decide whether continuing treatment is appropriate based on skin response.
1.3 Take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the PsARC and make any appropriate adjustments.
1.4 Take into account how skin colour could affect the PASI score and make any appropriate adjustments.
1.5 These recommendations are not intended to affect treatment with upadacitinib that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Why the committee made these recommendations
People with psoriatic arthritis that is not controlled well enough after 2 conventional DMARDs usually have biological DMARDs. Many of these are already recommended by NICE for treating psoriatic arthritis.
Clinical evidence shows that upadacitinib is more effective than placebo for treating active psoriatic arthritis and may be similarly as effective as adalimumab, another biological DMARD. But upadacitinib has not been directly compared with any other biological DMARD for this condition. The results of an indirect comparison are uncertain but suggest that upadacitinib is likely to work as well as other biological DMARDs.
The economic model showed that upadacitinib was not cost effective compared with some biological DMARDs for people who had not had a biological DMARD before. But it was cost effective for people who had had at least 1 biological DMARD or who could not have TNF-alpha inhibitors. So upadacitinib is recommended for these people.