Psoriatic Arthritis Treatment: Medications & Approaches

Psoriatic arthritis (PsA) is a chronic inflammatory condition that affects the joints and can also cause skin and nail changes. Managing PsA often involves a tailored approach to medication, adjusting treatments over time to achieve the best possible outcome. This strategy, known as “treat to target,” is increasingly recommended by experts, though it can present unique challenges compared to its use in other inflammatory diseases like rheumatoid arthritis.

Several classes of medications are used to treat psoriatic arthritis, most requiring a prescription. These treatments can be administered as pills, topical applications, subcutaneous injections, or intravenous (IV) infusions. The goal is to minimize disease activity, and for some, achieving remission – the absence of disease symptoms – is possible. Yet, for those with long-standing disease, a more realistic target may be low disease activity, meaning highly few signs of the condition are present.

Understanding Treatment Approaches

Traditionally, managing PsA involved addressing symptoms as they arose. However, the “treat to target” (T2T) approach, initially developed for conditions like diabetes and heart disease, has gained traction. In T2T, medications are regularly adjusted – dosage increased, modern drugs added, or even switching to a different class – based on how well a patient is responding. Monitoring can occur monthly, or less frequently, depending on disease activity and overall health. The Arthritis Foundation provides further detail on this process.

While T2T is now recommended by the American College of Rheumatology for PsA, it’s considered more complex than applying it to rheumatoid arthritis. What we have is because PsA can affect multiple areas of the body – joints, spine, skin, nails, fingers/toes (dactylitis), and where tendons/ligaments attach to bone (enthesitis). Improvement in one area doesn’t necessarily mean improvement in others, requiring a comprehensive assessment and individualized treatment plan.

Medication Options for Psoriatic Arthritis

Here’s a breakdown of common medication classes used to manage PsA:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs can help manage PsA symptoms, but they don’t prevent joint damage. Both over-the-counter options like ibuprofen (Advil, Motrin) and naproxen (Aleve), and prescription options like diclofenac (Arthrotec) are available. However, long-term use of oral NSAIDs can lead to stomach irritation, bleeding, and potentially increase the risk of heart attack and stroke. Topical NSAIDs offer an alternative for those unable to take oral medications.

Steroids (Glucocorticoids)

Steroids can reduce inflammation and alleviate pain, swelling, and stiffness. They can be taken orally, injected directly into a joint, or injected into swollen fingers or toes (dactylitis). Topical steroids can also be applied to fingernails or toenails affected by PsA. While effective, long-term systemic steroid use carries risks like weight gain, high blood sugar, and osteoporosis. Recent research suggests the risk of psoriasis flares after stopping steroid treatment may be lower than previously thought.

Disease-Modifying Antirheumatic Drugs (DMARDs)

DMARDs work by suppressing the immune system’s inflammatory response, slowing disease progression and preventing joint damage. These are typically taken orally, and it can take a month or more to determine if a DMARD is effective. Common DMARDs include methotrexate (Trexall), leflunomide (Arava), sulfasalazine (Azulfidine), azathioprine (Imuran, Azasan), and cyclosporine (Gengraf, Neoral, Sandimmune). Methotrexate is the most frequently used. Potential side effects include liver damage (requiring regular liver function tests) and gastrointestinal upset.

JAK Inhibitors

Janus kinase (JAK) inhibitors are a newer class of DMARDs that block enzymes involved in inflammation. Approved JAK inhibitors for PsA include tofacitinib (Xeljanz) and upadacitinib (Rinvoq). Side effects can include nausea, indigestion, and increased risk of infection. These medications carry warnings about potential risks of heart-related events, cancer, blood clots, and death. Testing for tuberculosis and other infections is required before starting treatment, along with periodic blood tests.

Phosphodiesterase-4 (PDE4) Inhibitors

PDE4 inhibitors, like apremilast (Otezla), target immune cells to reduce inflammation. They are taken as pills and can cause side effects such as headache, abdominal pain, and depression.

Biologics

Biologics target specific parts of the immune system to control inflammation. Different classes of biologics are used, including TNF-alpha inhibitors, IL-12/23 inhibitors, IL-17A inhibitors, IL-17A/F inhibitors, IL-23 inhibitors, and T-cell inhibitors. The American College of Rheumatology and National Psoriasis Foundation have guidelines on which biologic to use first, based on individual patient factors. Biologics are administered via subcutaneous injection or IV infusion. Infection screening is often required before starting biologic therapy.

The Importance of Collaboration with Your Rheumatologist

The treat-to-target approach requires frequent communication and collaboration with your rheumatologist. It’s crucial to discuss your personal treatment goals and priorities to ensure you’re on the same page and understand the process. Adjusting medications can be a dynamic process, and open dialogue with your healthcare provider is key to finding the most effective treatment plan for your individual needs. The National Psoriasis Foundation and the American College of Rheumatology have recently released joint treatment guidelines for psoriatic arthritis, offering evidence-based recommendations for care.

What to Expect Moving Forward

Treatment guidelines for PsA are continually evolving as research progresses. The American College of Rheumatology and National Psoriasis Foundation will likely update their recommendations as new evidence emerges. Ongoing clinical trials are investigating novel therapies and treatment strategies. Patients are encouraged to stay informed about the latest developments and discuss any concerns with their rheumatologist. Regular monitoring of disease activity and potential side effects remains a cornerstone of effective PsA management.