Psoriatic Arthritis Treatment & Management
- Author: Anwar Al Hammadi, MD, FRCPC; Chief Editor: Herbert S Diamond, MD more...
The treatment of psoriatic arthritis is directed at controlling the inflammatory process. Although no clear correlation exists between joint inflammation and the skin in every patient, the skin and joint aspects of the disease often must be treated simultaneously.
Based on evidence from systematic literature reviews and expert opinion, the European League Against Rheumatism (EULAR) developed 10 treatment recommendations, 5 overarching principles, and a research agenda for psoriatic arthritis. The recommendations are as follows :
NSAIDs can be administered for the relief of musculoskeletal signs and symptoms
Treatment with disease-modifying agents—eg, methotrexate, sulfasalazine, and leflunomide—should be considered at an early stage for patients with active disease
If a patient with active psoriatic arthritis also has clinically relevant psoriasis, preference should be given to treatment with methotrexate or other disease-modifying drugs that are also effective against psoriasis
Adjunctive treatment with local corticosteroid injections should be considered; cautious use of systemic steroids, if administered at the lowest effective dose, can also be considered
If active psoriatic arthritis fails to adequately respond to 1 or more synthetic, disease-modifying antirheumatic medications (eg, methotrexate), TNF-inhibitor therapy should be employed
TNF-inhibitor therapy should also be considered if a patient with active enthesitis and/or dactylitis does not show sufficient response to NSAIDs or local steroid injections
TNF-inhibitor therapy should be considered if a patient has active, predominantly axial disease that does not respond sufficiently to NSAIDs
Exceptional use of TNF-inhibitor therapy may be considered if a very active patient is disease-modifying ̶ treatment naïve
If a TNF inhibitor produces an inadequate response, consideration should be given to replacing it with another TNF inhibitor
If adjustments are made in a patient’s therapy, then comorbidities, safety concerns, and other considerations beyond the psoriatic arthritis itself should be factored into the change
British Society of Rheumatology recommendations
The British Society of Rheumatology (BSR) issued guidelines for the treatment of adult psoriatic arthritis with biologic agents (particularly anti-TNF] therapy).[50, 51] The BSR recommends considering anti-TNF treatment in patients with any of the following :
Active peripheral arthritis refractory to at least 2 conventional disease-modifying antirheumatic drugs (DMARDs)
Peripheral disease refractory to 1 DMARD plus the presence of adverse prognostic factors
Severe persistent oligoarthritis that is affecting well-being and refractory to at least 2 DMARDs and intra-articular therapy
The BSR recommendations on response assessment include the following :
Use the psoriatic arthritis response criteria as the clinical response criteria for peripheral disease
Use the psoriasis area severity index score for significant skin psoriasis
Safety recommendations include the following :
Do not start or continue anti-TNF therapy in patients with serious active infection; use caution in those at high risk of infection
Screen all patients for infection with mycobacteria, human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) before starting anti-TNF therapy
Consider prophylactic vaccination for tuberculosis and HBV in high-risk patients before initiating anti-TNF therapy
In patients with HIV, HBV, or HCV, initiate anti-TNF therapy only in those with well-controlled disease and appropriate monitoring; appropriate antiviral therapy for patients with HBV is also important
Avoid anti-TNF treatment in patients with a current or previous history of malignancy, unless there is a high likelihood of cure or the malignancy was diagnosed and treated more than 10 years ago
Regularly screen for skin cancers in patients who are receiving anti-TNF therapy and who have a history of current or previous malignancy
Discontinue anti-TNF therapy prior to pregnancy; restart anti-TNF treatment following the end of lactation or delivery if the mother is not breastfeeding
Consider an alternative anti-TNF agent in patients whose condition is refractory to a first anti-TNF agent; assess the treatment response as for the first agent
Medical treatment regimens include the use of NSAIDs and disease-modifying antirheumatic drugs (DMARDs). Although traditional therapy has consisted of NSAIDs and local corticosteroid injections, with DMARDs being reserved for NSAID-resistant cases, the finding that 40% of patients may develop erosive and deforming arthritis suggests that early, more aggressive treatment with DMARDs may be warranted.
DMARDs include methotrexate, sulfasalazine, cyclosporine, and leflunomide, as well as biologic agents (eg, anti–TNF-alpha medications, IL-12, IL-17, or -23 monoclonal antibodies).[3, 52, 53]
In September 2013, the FDA and the European Union approved ustekinumab, an interleukin-12/23 inhibitor, for the treatment of active psoriatic arthritis in adults who have not responded adequately to previous treatment with nonbiologic DMARDs. The drug was already approved in Europe and the United States for treatment of moderate to severe psoriatic plaques in adults.
Approval was based on 2 randomized, double-blind, placebo-controlled trials in 927 patients with active psoriatic arthritis who had at least 5 tender and 5 swollen joints and C-reactive protein levels of 0.3 mg/dL or higher despite previous conventional therapy. At week 24, 42% of patients receiving ustekinumab 45 mg and 50% of those receiving 90 mg achieved at least 20% improvement; at 52 weeks, this response was found to have been sustained. Treatment with ustekinumab also improved dactylitis, enthesitis, and skin component.
In the same month, the FDA also approved the TNF inhibitor certolizumab pegol (Cimzia) for the treatment of active psoriatic arthritis in adults. Approval was based on an ongoing, randomized, double-blind, placebo-controlled trial in 409 patients with active and progressive adult-onset psoriatic arthritis in which certolizumab-treated patients were significantly more likely to meet American College of Rheumatology 20%, 50%, and 70% response criteria by week 12 than placebo-treated patients. Certolizumab reduced radiographic progression and improved skin manifestations.
Apremilast (Otezla), was approved in March 2014 by the FDA for treatment of active psoriatic arthritis (PsA). It is a phosphodiesterase-4 (PDE4) inhibitor that is specific for cAMP, resulting in increased intracellular cAMP levels. Apremilast was evaluated in nearly 1500 patients with PsA. Patients received apremilast 30 mg PO BID plus concomitant therapy with at least 1 DMARD, methotrexate, leflunomide, oral corticosteroids, or NSAIDs. At week 6, improvement (ie, ACR20) was observed in 32-41% of patients. This was a statistically significant difference compared with placebo (p < 0.05).[56, 57, 58, 59]
Secukinumab (Cosentyx) is a human IgG1 monoclonal antibody that selectively binds to and neutralizes the proinflammatory cytokine interleukin 17A (IL-17A). IL-17A is a naturally occurring cytokine that is involved in normal inflammatory and immune responses. Secukinumab was approved by the FDA for adults with active psoriatic arthritis in January 2016.
Approval of secukinumab was based on the FUTURE 1 and 2 phase 3 trials. In the FUTURE 1 trial (n=606), the American College of Rheumatology 20 (ACR20) response rates at week 24 were significantly higher in the group receiving secukinumab at doses of 150 mg (50.0%) and 75 mg (50.5%) than in those receiving placebo (17.3%) (P<0.001 for both comparisons with placebo). In FUTURE 2, patients were randomly assigned to receive secukinumab 300 mg (n=100), 150 mg (n=100), 75 mg (n=99), or placebo (n=98). A significantly higher proportion of patients achieved an ACR20 at week 24 with secukinumab doses of 300 mg (54%; P<0.0001) and 150 mg (51%; P<0.0001) compared with placebo (15%).
In patients with severe skin inflammation, medications such as methotrexate, retinoic-acid derivatives, and psoralen plus ultraviolet (UV) light should be considered. These agents have been shown to work on skin and joint manifestations.
Intolerance to methotrexate was observed in 14.3% of patients with PsA in a cross-sectional study (n=291), as measured with the Methotrexate Intolerance Severity Score (MISS). GI symptoms, including nausea, abdominal pain, and vomiting, occurred during methotrexate treatment in 123 patients (42.3%); behavioral symptoms, including restlessness and irritability, were also common. Methotrexate intolerance was more common with parenteral (20.6%) than oral (6.2%) administration.[60, 61]
Intra-articular injection of entheses or single inflamed joints with corticosteroids may be particularly effective in some patients. Use disease-modifying drugs in individuals whose arthritis is persistent. If the skin disease is well controlled with topical medication, the joint disease can be treated with a variety of second-line or cytotoxic drugs. Intramuscular administration of gold has been used in the past but has been supplanted by newer DMARDs.
In a study completed by the Psoriatic Arthritis Study Group, patients with psoriasis and psoriatic arthritis who were receiving stable doses of methotrexate were found to benefit from the addition of 1 or more courses of intramuscular alefacept, a T-cell inhibitor via a human lymphocyte function–associated antigen 3 (LFA-3) Fc fusion protein that blocks the interaction between CD2 on T cells and LFA-3 on antigen-presenting cells. Further benefit in psoriatic arthritis was apparent after a second course of alefacept, and no additional toxicity was observed.
Sulfasalazine and cyclosporine are 2 second-line DMARDs that have received particular attention in the management of psoriatic arthritis. Although these drugs may control the acute inflammation in persons with psoriatic arthritis, they have not been helpful in arresting the progression of clinical and radiologic damage. Thus, the disease must be treated earlier or better drugs are necessary, to prevent the damage that may ensue as a result of psoriatic arthritis.
Cyclosporine appears to be an effective agent for the treatment of psoriasis and psoriatic arthritis. The major concern with this drug is its toxicity, especially its nephrotoxicity, and hypertension.
Combination therapy (eg, methotrexate/sulfasalazine, methotrexate/cyclosporine) may be more efficacious in some patients.
Several other agents have been tried in persons with psoriatic arthritis, including vitamin D-3, bromocriptine, peptide T, and fish oils, but their efficacy remains to be proven.
Antimalarials, particularly hydroxychloroquine, are usually avoided in patients with psoriasis for fear of precipitating exfoliative dermatitis or exacerbating psoriasis. However, 2 studies showed that these reactions did not occur in patients who were treated with hydroxychloroquine; therefore, this drug is occasionally used to treat psoriatic arthritis.
Systemic corticosteroids are usually avoided because of possible rebound of the skin disease upon withdrawal.
The rehabilitation treatment program for patients with psoriatic arthritis should be individualized and should be started early in the disease process. Such a program should consider the use of the following:
Rest: Local and systemic
Exercise: Passive, active, stretching, strengthening, and endurance
Modalities: Heat and cold treatments can temporarily relieve pain and reduce joint swelling; such treatments include soaking in a warm tub or placing a warm compress or cold pack on the painful joint
Orthotics: Upper and lower extremities, spinal
Assistive devices for gait and adaptive devices for self-care tasks: Including possible modifications to homes and automobiles
Education about the disease, energy conservation techniques, and joint protection
Possible vocational readjustments
With regard to the first item above, prolonged rest should be avoided to prevent the deleterious effects of immobility. In a very few people, psoriatic arthritis may cause extreme fatigue.
Encourage rest as indicated. Splints may be used for rest and pain relief, especially for the hands, wrists, knees, or ankles. Cold modalities should be used to decrease inflammation and assist with pain relief. Joints should not be moved beyond the limit of pain; passive movements should be limited at this time. Education should be completed during this phase, with topics including the disease itself, the importance of rest, the exercise program, joint protection, energy conservation, and weight loss, if appropriate.
Subacute and long-term phase
Isometric exercises are begun, with progression to active movement. Gradual range-of-motion (ROM) exercises include passive and active exercises; areas with subluxation should not be forced passively. Heating modalities, including moist heat packs, paraffin wax, diathermy, and ultrasound, can be used to decrease pain; heat therapy should be administered just prior to the performance of ROM exercises.
Institute gait activities, with the patient bearing weight as tolerated, with or without an assistive device. Gentle stretching should be gradually introduced. If pain persists beyond 2 hours after therapies, then the intensity should be decreased. If a joint is swollen, then no resistive exercises should be performed through full ROM.
For patients with axial spine involvement, spine extension exercises help with flexibility and strength. ROM exercises should be performed, but not in patients with increased pain.
If the patient has sausage toes, extra-depth shoes with a high toe box should be considered to protect the foot. With pain in the toes, such shoes should have a rocker-bottom modification to alleviate forces during the toe-off phase in the gait cycle. The patient may also benefit from arch supports if plantar fascitis is a problem.
Synovectomy and Arthroplasty
Currently, no prospective studies are addressing surgical intervention in patients with psoriatic arthritis. Patients in severe pain or with significant contractures may be referred for possible surgical intervention. Treatment should be aimed at pain relief or increasing the patient's function.
Arthroscopic synovectomy has been effective in treating severe, chronic, monoarticular synovitis. Because of an enhanced tendency for patients to develop fibrosis in association with this therapy, anti-inflammatory and physical therapy measures aimed at improving ROM are important adjuncts to this intervention.
Joint replacement and forms of reconstructive therapy are occasionally necessary. Hip and knee joint replacements have been successful, for the most part, in patients with psoriatic arthritis. Arthrodesis and arthroplasty have also been used on joints, such as the proximal interphalangeal joint of the thumb. The wrist often spontaneously fuses, and this may relieve the patient's pain without surgical intervention.
Because of the diffuse soft-tissue involvement that is associated with psoriatic arthritis, high rates of recurrence of joint contractures have been noted after surgical release, especially in the hand.
For arthritis mutilans, surgical intervention is usually directed toward salvage of the hand. Combinations of arthrodesis, arthroplasty, and bone grafts to lengthen the digits may be used. The goal is to maintain the pinch mechanism of the thumb and the first 2 fingers.
If the patient's physiatrist feels uncomfortable with prescribing medications for psoriatic arthritis, referral to a rheumatologist with more experience with these agents may be advisable. The physiatrist may then concentrate on functional restoration of the patient. Referral to a surgeon should be considered for appropriate patients.
with juvenile psoriatic arthritis should be examined by an ophthalmologist annually to check for the several forms of eye inflammation usually associated with various forms of juvenile arthritis.
Given the complexity of DMARD therapy, patients with psoriatic arthritis should be followed simultaneously by a rheumatologist and physiatrist. In addition, consultation with an orthopedic surgeon is warranted for individuals who may benefit from joint replacement, arthrodesis, or contracture release.
Deterrence and Prevention
A number of medications can exacerbate psoriasis; therefore, avoidance of these agents may help to prevent or minimize flare-ups. Lithium and withdrawal from systemic corticosteroids are well known to cause disease flare-ups.
Other drugs that have been implicated include beta blockers, antimalarials (although, as previously mentioned, evidence suggests that hydroxychloroquine does not exacerbate skin lesions), and NSAIDs. If skin lesions worsen with an NSAID, switch to a different family of NSAID.
Prevention includes rest and exercise. Joint protection, including splints, braces, and other supports, may be helpful. No definitive prevention exists, because this is a chronic disease that can wax and wane.
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|Laboratory Studies||Psoriatic Arthritis||Rheumatoid Arthritis|
|Erythrocyte sedimentation rate||Elevated (< 100)||Elevated (< 100)|
|Rheumatoid factor||Negative||Positive (85% of patients)|
|Antinuclear antibody||Negative||Positive (30% of patients)|
|Synovium||WBC count 5000-15,000/µL, >50% polymorphonuclear leukocytes||WBC count 2000/µL|