Psoriatic Arthritis Treatment
Publication Date: November 30, 2018
Treatment
Treatment
Notes and Definitions
- Active psoriatic arthritis (PsA) is defined as disease causing symptoms at an unacceptably bothersome level as reported by the patient, and judged by the examining clinician to be due to PsA based on ≥1 of the following: swollen joints, tender joints, dactylitis, enthesitis, axial disease, active skin and/or nail involvement, and extraarticular inflammatory manifestations such as uveitis or inflammatory bowel disease.
- In the absence of published studies, the best evidence came from the collective experience of the voting panel and patient panel members, which was designated very-low-quality evidence.
- Because there are currently no widely agreed-upon definitions of disease severity, PsA severity should be established by the health care provider and patient on a case-by-case basis. For the purposes of these recommendations, severity is considered a broader concept than disease activity in that it encompasses the level of disease activity at a given time point, as well as the presence of poor prognostic factors and long-term damage. Examples of severe PsA disease include the presence of ≥1 of the following: a poor prognostic factor (erosive disease, elevated levels of inflammation markers such as C-reactive protein or erythrocyte sedimentation rate attributable to PsA), long-term damage that interferes with function (e.g., joint deformities, vision loss), highly active disease that causes major impairment in quality of life (i.e., active psoriatic inflammatory disease at many sites [including dactylitis, enthesitis] or function-limiting inflammatory disease at few sites), and rapidly progressive disease.
- Because there are currently no widely agreed-upon definitions of disease severity, psoriasis severity should be established by the health care provider and patient on a case-by-case basis. In clinical trials, severe psoriasis has been defined as a Psoriasis Area and Severity Index (PASI) score 25 of ≥12 and a body surface area score of ≥10. In clinical practice, however, the PASI tool is not standardly utilized given its cumbersome nature. In 2007, the National Psoriasis Foundation published an expert consensus statement, which defined moderate-to-severe disease as a body surface area of ≥5%. In cases in which the involvement is in critical areas, such as the face, hands or feet, nails, intertriginous areas, scalp, or where the burden of the disease causes significant disability or impairment of physical or mental functioning, the disease can be severe despite the lower amount of surface area of skin involved. The need to factor in the unique circumstances of the individual patient is of critical importance, but this threshold provides some guidance in the care of patients.
- Oral small molecules (OSMs) are defined as methotrexate (MTX), sulfasalazine, leflunomide, cyclosporine, or apremilast and do not include tofacitinib, which was handled separately since its efficacy/safety profile is much different from that of other OSMs.
- OSM- and other treatment–naïve is defined as naïve to treatment with OSMs, tumor necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i), and IL-12/23i; patients may have received nonsteroidal antiinflammatory drugs, glucocorticoids, and/or other pharmacologic and nonpharmacologic interventions.
Figure 1. Pharmacologic, Nonpharmacologic, and Symptomatic Therapies for PsA
| Non-pharmacologic therapies | physical therapy, occupational therapy, smoking cessation, weight loss, massage therapy, exercise |
| Symptomatic treatments | nonsteroidal anti-inflammatory drugs, glucocorticoids, local glucocorticoid injections |
| OSM | methotrexate, sulfasalazine, cyclosporine, leflunomide, apremilast |
| TNFi | etanercept, infliximab, adalimumab, golimumab, certolizumab pegol |
| IL12/23i | ustekinumab |
| IL17i | secukinumab, ixekizumab, brodalumab |
| CTLA4-Ig | abatacept |
| JAK inhibitor | tofacitinib |
Figure 2. Examples of “Severe” PsA and Psoriasis
| Severe Psoriatic Arthritis | Severe Psoriasis |
|---|---|
|
|
The guideline development group defined severe PsA and psoriasis as the presence of 1 or more of the items listed. This is not a formal definition. There have been many definitions of severe psoriasis used over time—the items here are adapted from the 2007 National Psoriasis Foundation (NPF) expert consensus statement for moderate-to-severe psoriasis. In clinical trials, severe psoriasis has been defined as a Psoriasis Area and Severity Index (PASI) score of ≥12 and a body surface area (BSA) score of ≥10.
Table 1. Recommendations for the Initial Treatment of Patients With Active PsA Who Are OSM- and Other Treatment-Naïve
In OSM- and other treatment–naïve patients with active PsA:
Treat with a TNFi biologic over an OSM (MTX, SSZ, LEF, CSA, or APR)
May consider an OSM if the patient does not have severe PsA, does not have severe psoriasis, prefers oral therapy, has concern over starting a biologic as the first therapy, or has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Low )
607
Treat with a TNFi biologic over an IL-17i biologic
May consider an IL-17i biologic if the patient has severe psoriasis or has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Treat with a TNFi biologic over an IL-12/23i biologic
May consider an IL-12/23i biologic if the patient has severe psoriasis, prefers less frequent drug administration, or has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Treat with an OSM over an IL-17i biologic
May consider an IL-17i biologic if the patient has severe psoriasis and/or severe PsA. ( Conditional , Very Low )
607
Treat with an OSM over an IL-12/23i biologic
May consider an IL-12/23i biologic if the patient has concomitant IBD and/or severe psoriasis and/or severe PsA or prefers less frequent drug administration. ( Conditional , Very Low )
607
Treat with MTX over NSAIDs
May consider NSAIDs before starting MTX in patients with less active disease, after careful consideration of cardiovascular risks and renal risks of NSAIDs. ( Conditional , Very Low )
607
Treat with an IL-17i biologic over an IL-12/23i biologic
May consider an IL-12/23i biologic if the patient has concomitant IBD or prefers less frequent drug administration. ( Conditional , Very Low )
607
Figure 3. Patients with Active PsA Who are Treatment-Naïve (no exposure to OSMs)
Table 2. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an OSM
In adult patients with active PsA despite treatment with an OSM
Switch to a TNFi biologic over a different OSM
May consider switching to a different OSM if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, if the patient prefers an oral versus parenteral therapy, or in patients without evidence of severe PsA or severe psoriasis. ( Conditional , Moderate )
607
Switch to a TNFi biologic over an IL-17i biologic
May consider an IL-17i if the patient has severe psoriasis and/or has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, and/or a family history of demyelinating disease such as multiple sclerosis. ( Conditional , Moderate )
607
Switch to a TNFi biologic over an IL-12/23i biologic
May consider an IL-12/23i if the patient has severe psoriasis and/or contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or prefers less frequent drug administration. ( Conditional , Moderate )
607
Switch to a TNFi biologic over abatacept
May consider abatacept if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Low )
607
Switch to a TNFi biologic over tofacitinib
May consider tofacitinib if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or prefers oral medication. ( Conditional , Low )
607
Switch to an IL-17i over a different OSM
May consider switching to a different OSM if the patient prefers an oral versus parenteral therapy or in patients without evidence of severe PsA or severe psoriasis. ( Conditional , Low )
607
Switch to an IL-17i biologic over an IL-12/23i biologic
May consider an IL-12/23i biologic if the patient has concomitant IBD or prefers less frequent drug administration. ( Conditional , Moderate )
607
Switch to an IL-17i biologic over abatacept
May consider abatacept in patients with recurrent or serious infections. ( Conditional , Low )
607
Switch to an IL-17i biologic over tofacitinib
May consider tofacitinib if the patient prefers an oral therapy or has a history of recurrent Candida infections. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over a different OSM
May consider switching to a different OSM if the patient prefers an oral versus parenteral therapy or in patients without evidence of severe PsA or severe psoriasis. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over abatacept
May consider abatacept in patients with recurrent or serious infections. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over tofacitinib
May consider tofacitinib if the patient prefers an oral therapy. ( Conditional , Low )
607
Add apremilast to current OSM therapy over switching to apremilast
May consider switching to apremilast if the patient has intolerable side effects with the current OSM. ( Conditional , Low )
607
Switch to another OSM (except apremilast) over adding another OSM (except apremilast) to current treatment
May consider adding another OSM (except apremilast) to current treatment if the patient has demonstrated partial response to the current OSM. ( Conditional , Low )
607
Switch to a TNFi biologic monotherapy over MTX and a TNFi biologic combination therapy
May consider MTX and TNFi biologic combination therapy if the patient has severe skin manifestations, has had a partial response to current MTX therapy, has concomitant uveitis (since uveitis may respond to MTX therapy), and if the current TNFi biologic is infliximab or adalimumab. ( Conditional , Low )
607
Switch to an IL-17i biologic monotherapy over MTX and an IL-17i biologic combination therapy
May consider MTX and an IL-17i biologic combination therapy if the patient has severe skin manifestations, has had a partial response to current MTX therapy, or has concomitant uveitis (since uveitis may respond to MTX therapy). ( Conditional , Very Low )
607
Switch to an IL-12/23i biologic monotherapy over MTX and an IL-12/23i biologic combination therapy
May consider MTX and an IL-12/23i biologic combination therapy if the patient has severe skin manifestations, has had a partial response to current MTX therapy, or has concomitant uveitis (since uveitis may respond to MTX therapy). ( Conditional , Very Low )
607
Figure 4. Patients with Active PsA Despite Treatment With OSMs
Table 3. Recommendations for Treatment of Patients With Active PsA Despite Treatment With a TNFi Biologic, as Monotherapy or in Combination with MTX
In adult patients with active PsA despite treatment with a TNFi biologic monotherapy:
Switch to a different TNFi biologic over switching to an IL-17i biologic
May consider an IL-17i if the patient had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse event or severe psoriasis. ( Conditional , Low )
607
Switch to a different TNFi biologic over switching to an IL-12/23i biologic
May consider an IL-12/23i if the patient had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse effect or prefers less frequent drug administration. ( Conditional , Low )
607
Switch to a different TNFi biologic over switching to abatacept
May consider abatacept if the patient had a primary TNFi biologic efficacy failure or TNFi biologic–associated serious adverse effect. ( Conditional , Low )
607
Switch to a different TNFi biologic over switching to tofacitinib
May consider tofacitinib if the patient prefers an oral therapy or had a primary TNFi biologic efficacy failure or a TNFi biologic–associated serious adverse effect. ( Conditional , Low )
607
Switch to a different TNFi biologic (with or without MTX) over adding MTX to the same TNFi biologic monotherapy
May consider adding MTX when patients have demonstrated partial response to the current TNFi biologic therapy, especially if the TNFi biologic is a monoclonal antibody. ( Conditional , Very Low )
607
Switch to an IL-17i biologic over switching to an IL-12/23i biologic
May consider an IL-12/23i if the patient has IBD or if the patient prefers less frequent drug administration. ( Conditional , Low )
607
Switch to an IL-17i biologic over abatacept
May consider abatacept if the patient prefers IV dosing or in patients with recurrent or serious infections. ( Conditional , Low )
607
Switch to an IL-17i biologic over tofacitinib
May consider tofacitinib if the patient prefers an oral therapy or in patients with concomitant IBD or a history of recurrent Candida infections. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over abatacept
May consider abatacept if the patient prefers IV dosing or in patients with recurrent or serious infections. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over tofacitinib
May consider tofacitinib if the patient prefers an oral therapy. ( Conditional , Low )
607
Switch to a different TNFi biologic monotherapy over switching to a different TNFi biologic and MTX combination therapy
May consider switching to a TNFi biologic and MTX combination therapy if the current TNFi biologic is infliximab ( Conditional , Very Low )
607
Switch to an IL-17i biologic monotherapy over switching to an IL-17i biologic and MTX combination therapy
May consider switching MTX combination therapy in patients with concomitant uveitis, since uveitis may respond to MTX therapy. ( Conditional , Very Low )
607
Switch to an IL-12/23i biologic monotherapy over switching to an IL-12/23i biologic and MTX combination therapy
May consider switching to an IL-12/23i biologic and MTX combination therapy if the patient has severe psoriasis. ( Conditional , Very Low )
607
In adult patients with active PsA despite treatment with a TNFi biologic and MTX combination therapy:
Switch to a different TNFi biologic + MTX over switching to a different TNFi biologic monotherapy
-associated adverse events, prefers to receive fewer medications, or perceives MTX as a burden. ( Conditional , Very Low )
607
Switch to an IL-17i biologic monotherapy over an IL-17i biologic and MTX combination therapy
May consider switching to an IL-17i biologic and MTX combination therapy if the patient had had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL-17i biologic was discussed as potentially beneficial to allow the new therapy time to work. ( Conditional , Very Low )
607
Switch to IL-12/23i biologic monotherapy over IL-12/23i biologic and MTX combination therapy
May consider switching to an IL-12/23i biologic and MTX combination therapy if the patient had had a partial response to the existing regimen or in patients with concomitant uveitis, as uveitis may respond to MTX therapy. Continuing MTX during the transition to an IL-12/23i biologic was discussed as potentially beneficial to allow the new therapy time to work. ( Conditional , Low )
607
Figure 5. Patients with Active PsA Despite Treatment With a TNFi as Monotherapy or as Combination Therapy with MTX
Table 4. Recommendations for Treatment of Patients With Active PsA Despite Treatment With an IL-17i or an IL-12/23i Biologic Monotherapy
In adult patients with active PsA despite treatment with an IL-17i biologic monotherapy:
Switch to a TNFi biologic over switching to an IL-12/23i biologic
May consider switching to IL-12/23i if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or prefers less frequent drug administration. ( Conditional , Very Low )
607
Switch to a TNFi biologic over switching to a different IL-17i biologic
May consider switching to a different IL-17i if the patient had had a secondary efficacy failure to current IL-17i, or severe psoriasis, or contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Switch to a TNFi biologic over adding MTX to an IL-17i biologic
May consider adding MTX to an IL-17i if the patient had had a partial response to the existing regimen or if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Switch to an IL-12/23i biologic over switching to a different IL-17i biologic
May consider switching to a different IL-17i if the patient had had a secondary efficacy failure to current IL-17i or severe psoriasis, or if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Switch to an IL-12/23i biologic over adding MTX to an IL-17i biologic
May consider adding MTX to an IL-17i if the patient had had a partial response to the existing regimen. ( Conditional , Very Low )
607
In adult patients with active PsA despite treatment with an IL-12/23i biologic monotherapy:
Switch to a TNFi biologic over switching to an IL-17i biologic
May consider an IL-17i if the patient has severe psoriasis or contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Switch to a TNFi biologic over adding MTX to an IL-12/23i biologic
May consider adding MTX in patients in whom the severe psoriasis is not responding to the current therapy, or if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
Switch to an IL-17i biologic over adding MTX to an IL-12/23i biologic
May consider adding MTX in partial response to the current therapy or in those who potentially have not had enough time to adequately respond. ( Conditional , Very Low )
607
Figure 6. Patients with Active PsA Despite Treatment With IL-17i or IL-12/23i Biologic Monotherapy
Table 5. Recommendations for Treatment of Patients With Active PsA Including Treat-To-Target, Active Axial Disease, Enthesitis, or Active IBD
In adult patients with active PsA:
Use a treat-to-target strategy over not following a treat-to-target strategy
May consider not following a treat-to-target strategy in patients in whom higher frequency and/or severity of adverse events, higher cost of therapy, or higher patient burden of medications with tighter control are a concern. ( Conditional , Low )
607
In patients with active PsA with psoriatic spondylitis/axial disease despite treatment with NSAIDs:a
Axial disease is generally treated according to the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for spondyloarthritis (aSpA).
Switch to a TNFi biologic over switching to an IL-17i biologic
May consider switching to an IL-17i biologic if the patient has contraindications to TNFi biologics, congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or if the patient has severe psoriasis. ( Conditional , Very Low )
607
Switch to a TNFi biologic over switching to an IL-12/23i biologic
Switching to an IL-12/23i biologic is not considered since recent trials in axial SpA were stopped. ( Conditional , Very Low )
607
Switch to an IL-17i biologic over switching to an IL-12/23i
Switching to an IL-12/23i biologic is not considered since recent trials in axial SpA were stopped. ( Conditional , Very Low )
607
In adult patients with active PsA and predominant enthesitis who are both OSM- and biologic treatment-naïve:
Start oral NSAIDs over an OSM (specifically apremilast)
May consider starting an OSM (specifically apremilast) if the patient has active joint disease and/or skin disease or contraindications to the use of NSAIDs, including cardiovascular disease, peptic ulcer disease, or renal disease or impairment. ( Conditional , Very Low )
607
Start a TNFi biologic over an OSM (specifically apremilast)
May consider starting an OSM (specifically apremilast) if the patient prefers an oral treatment as the first therapy or the patient has contraindications to TNFi biologics, including recurrent infections, congestive heart failure, or demyelinating disease. ( Conditional , Very Low )
607
Start tofacitinib over an OSM (specifically apremilast)
May consider starting an OSM (specifically apremilast) if the patient has recurrent infections. ( Conditional , Very Low )
607
In adult patients with active PsA and predominant enthesitis despite treatment with OSM:b
b It should be noted that for the enthesitis questions, the existing evidence was mainly drawn from the apremilast studies, as no randomized controlled trial report described enthesitis outcomes for the other OSMs.
Switch to a TNFi biologic over an IL-17i biologic
May consider switching to an IL-117i if the patient has severe psoriasis or contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Low )
607
Switch to a TNFi biologic over an IL-12/23i biologic
May consider switching to an IL-12/23i if the patient has severe psoriasis or contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or if the patient prefers less frequent drug administration. ( Conditional , Low )
607
Switch to a TNFi biologic over switching to another OSM
May consider switching to another OSMb if the patient prefers an oral medication over an injection, or if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Low )
607
Switch to an IL-17i biologic over an IL-12/23i biologic
May consider switching to an IL-12/23i if the patient has concomitant IBD or if the patient prefers less frequent drug administration. ( Conditional , Low )
607
Switch to an IL-17i biologic over switching to another OSM
May consider switching to another OSM if the patient prefers an oral medication. ( Conditional , Low )
607
Switch to an IL-12/23i biologic over switching to another OSM
May consider switching to another OSMb if the patient prefers an oral medication over an injection, or if there are contraindications to an IL-12/23i, such as severe recurrent infections. ( Conditional , Low )
607
In adult patients with active PsA and concomitant active IBD who are both OSM- and biologic treatment-naïve:
Start a monoclonal antibody TNFi biologic over an OSM
May consider starting an OSM if the patient prefers an oral medication, or if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. ( Conditional , Very Low )
607
In adult patients with active PsA and concomitant active IBD despite treatment with an OSM:
Switch to a monoclonal antibody TNFi biologic over a TNFi biologic soluble receptor biologic (i.e., etanercept)
TNFi monoclonal antibody biologics are effective in IBD but indirect evidence shows a TNFi biologic soluble receptor biologic is not effective for the treatment of IBD. ( Strong , Moderate )
607
Switch to a TNFi monoclonal antibody biologic over an IL-17i biologic
Monoclonal antibody TNFi biologics are effective for IBD while an IL-17i biologic is not effective for IBD. ( Strong , Moderate )
607
Switch to a TNFi biologic monoclonal antibody biologic over an IL-12/23i biologic
May consider switching to an IL-12/23i biologic if the patient has contraindications to TNFi biologics, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease, or prefers less frequent drug administration. ( Conditional , Very Low )
607
Switch to an IL-12/23i biologic over switching to an IL-17i biologic
IL-12/23i biologic is effective for IBD while an IL-17i biologic is not effective for IBD. ( Strong , Moderate )
607
Table 6. Recommendations for Treatment of Patients With Active PsA and Comorbidities, Including Concomitant Diabetes and Recurrent Serious Infections
In adult patients with active PsA and diabetes who are both OSM- and biologic treatment–naïve:
Start an OSM other than MTX over a TNFi biologic
May consider starting a TNFi, if the patient has severe PsA or severe/active skin disease, when diabetes is well controlled. ( Conditional , Very Low )
607
In adult patients with active PsA and frequent serious infections who are both OSM- and biologic treatment–naïve:
Start an OSM over a TNFi biologic
There is a black box warning against the use of a TNFi biologic with regard to increased risk of serious infection. ( Strong , Moderate )
607
Start an IL-12/23i biologic over a TNFi biologic
May consider starting a TNFi if the patient has severe PsA. ( Conditional , Very Low )
607
Start an IL-17i biologic over a TNFi biologic
May consider starting a TNFi in patients with concomitant IBD. ( Conditional , Very Low )
607
Table 7. Recommendations for Vaccination in Patients With Active PsA
In adult patients with active PsA needing vaccinations:a
a Vaccines as indicated by patient age, sex, and immunization history per recommendations from the Centers for Disease Control and Prevention and available at: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
Start the biologic and administer killed vaccines over delaying the start of biologic to administer killed vaccines
May consider delaying the start of biologic to administer killed vaccines due to patient preference based on patient belief about vaccine efficacy. ( Conditional , Very Low )
607
Delay the start of biologic to administer live attenuated vaccines over starting the biologic and administering live attenuated vaccines
May consider starting the biologic and administering live attenuated vaccines in patients with very active severe joint or skin disease who prefer no delay in biologic initiation. ( Conditional , Very Low )
607
Table 8. Recommendations for Treatment of Patients With Active PsA With Nonpharmacologic Interventions
In adult patients with active PsA:
Recommend exercise over no exercise
May consider no exercise in patients with existing muscle/tendon injury or multiple inflamed symptomatic joints with worsening pain with exercise. ( Conditional , Low )
607
Recommend low-impact exercise (e.g., tai chi, yoga, swimming) over high-impact exercise (e.g., running)
May consider high-impact exercise due to patient preference. ( Conditional , Very Low )
607
Recommend physical therapy over no physical therapy
May consider no physical therapy due to patient preference, out-of-pocket cost, distance to physical therapy site, or lack of transportation. ( Conditional , Very Low )
607
Recommend occupational therapy over no occupational therapy
May consider no occupational therapy due to patient preference, out-of-pocket cost, distance to occupational therapy site, or lack of transportation. ( Conditional , Low )
607
Recommend weight loss over no weight loss for patients who are overweight/obese
May consider no weight loss due to additional patient burden involved with weight-loss program. ( Conditional , Low )
607
Recommend massage therapy over no massage therapy
May consider no massage therapy due to associated costs. ( Conditional , Very Low )
607
Recommend acupuncture over no acupuncture
May consider no acupuncture due to associated costs. ( Conditional , Very Low )
607
Recommend smoking cessation over no smoking cessation
The evidence was rated down for indirectness to moderate level. ( Strong , Moderate )
607