Guselkumab and structural damage in erosive psoriatic arthritis
Arthritis & Rheumatology · 20 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
Psoriatic arthritis can cause erosive hand and foot joint destruction that orthopaedic surgeons may later reconstruct, so knowing which biologics slow radiographic damage helps with referral and with counselling before surgery.
The evidence
APEX randomised 1020 biologic-naive adults with active, erosive psoriatic arthritis to guselkumab (an IL-23 blocker) every 4 or every 8 weeks or to placebo, with placebo patients switched to guselkumab at week 24. The primary week 24 endpoint, reported earlier, favoured guselkumab (ACR20 67% and 68% vs 47% with placebo). This week 48 report, where all patients were on drug after week 24 and no formal testing was done, found ACR20 rates of 71% and 74% and small x-ray damage scores (vdH-S change 0.24 to 0.32 points from week 24 to 48); patients switched from placebo had less progression after switching (0.96 points in weeks 0 to 24 vs 0.41 in weeks 24 to 48).
A coherent primary effect estimate is unavailable. Clinical relevance does not estimate treatment benefit.
Why this rigour score?
Sham-controlled RCTDesign starting point: 68.6
Raised the score
- Sham / placebo control+11.9
- Prospectively registered+5.1
Lowered the score
- Per-protocol analysis only−6
Methods at a glance
Recorded assessment- Outcome assessors blindedMet
- Allocation concealedNot reported
- Random sequence generatedNot reported
- Intention-to-treat analysisNot met
- Adequate statistical powerNot reported
- Prospective registrationMet
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 68.6
- Sham-controlled
- +6.8
- Placebo or sham control
- +5.1
- Blinded outcome assessment
- +3.4
- Per-protocol analysis only
- −6
- 0% loss to follow-up
- +1.7
- Prospectively registered
- +5.1
- Journal prior (not an observed method)
- +0.4
- Final rigour score rounded
- 85 / 100
Study design sets the starting point and a ceiling of 100. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.For a patient with psoriatic arthritis who already has hand or foot erosions, how should evidence of slowed radiographic progression on an IL-23 inhibitor influence the timing of referral to rheumatology versus surgical reconstruction?
2.How would you counsel a patient on an IL-23 inhibitor who needs elective orthopaedic surgery about infection risk and whether to hold or continue the drug around the operation?
Original publication title
Sustained Inhibition of Structural Damage Progression and Improvements in Disease Activity With Guselkumab in Biologic‐Naïve Participants with Active and Erosive Psoriatic Arthritis: Results Through Week 48 of the Phase 3b Randomized, Double‐Blind, Placebo‐Controlled APEX Study