From the Guidelines
Rheumatoid arthritis, proctitis, and psoriatic arthritis require distinct treatment approaches, with a focus on minimizing morbidity, mortality, and improving quality of life, as evident from the 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis 1.
Treatment Approaches
- For rheumatoid arthritis, initial treatment typically includes methotrexate starting at 7.5-10mg weekly and gradually increasing to 20-25mg weekly, often combined with folic acid supplementation.
- For proctitis, treatment depends on the cause, with ulcerative proctitis typically managed using mesalamine suppositories (1g daily) or enemas, and oral sulfasalazine (2-4g daily in divided doses) for more extensive disease.
- Psoriatic arthritis treatment often begins with NSAIDs like celecoxib (200mg daily) for mild cases, while moderate to severe cases require methotrexate (15-25mg weekly) or biologics like adalimumab (40mg every other week) or etanercept (50mg weekly), as recommended by the 2018 guideline 1.
Key Considerations
- Regular monitoring for medication side effects is essential, including liver function tests for methotrexate and tuberculosis screening before starting biologics.
- These conditions are driven by dysregulated immune responses, with rheumatoid arthritis primarily affecting synovial joints, proctitis involving rectal inflammation, and psoriatic arthritis combining joint inflammation with skin manifestations.
- Early identification and treatment of psoriatic arthritis are crucial for improving long-term outcomes, as highlighted in the guideline 1.
Treatment Goals
- The primary goal of treatment is to minimize morbidity, mortality, and improve quality of life, which can be achieved through a combination of pharmacologic and nonpharmacologic therapies.
- The treatment approach should be individualized, taking into account the severity of the disease, patient preferences, and potential side effects of medications, as emphasized in the guideline 1.
From the Research
Rheumatoid Arthritis, Proctitis, and Psoriatic Arthritis
- Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are two distinct forms of chronic inflammatory arthritis, with different clinical presentations, radiographic findings, comorbidities, and pathogenesis 2.
- PsA is characterized by skin and joint manifestations, and is frequently undiagnosed or misdiagnosed due to similarities with other arthritic diseases, including RA and osteoarthritis (OA) 3.
- The treatment of PsA has changed substantially over the past 10 years, with clinical practice guidelines developed to help clinicians integrate evolving knowledge of therapeutic management into practice 4.
- Adalimumab, a fully human monoclonal antibody against TNF α, is effective and reasonably safe in the short- and long-term treatment of patients with RA, ankylosing spondylitis, and PsA who do not respond to standard therapy 5.
Risk Factors and Comorbidities
- Risk factors for PsA include obesity, pharyngitis, and skin infections, while shared risk factors with PsO include obesity and moderate alcohol intake 6.
- PsA and AS are associated with uveitis, while PsA and RA are associated with preceding gout 6.
- Current smoking, former moderate drinking, anemia, osteoporosis, and inflammatory bowel disease are associated with both RA and AS 6.
- Statin use is inversely associated with all four conditions: PsA, PsO, RA, and AS 6.
Diagnosis and Differentiation
- Accurate and timely diagnosis of PsA is crucial to prevent delays in optimal treatment, which can lead to irreversible joint damage and increased functional disability 3.
- Differentiation of PsA from RA and OA can be facilitated by characteristic features such as clinical manifestations, biomarkers, radiologic features, and therapeutic recommendations 3.
- Joint involvement is typically asymmetric in PsA, while it is predominantly symmetric in RA, and bone erosions, without new bone growth, and cervical spine involvement are distinctive of RA 2.