From the Guidelines
The initial treatment approach for patients with psoriatic arthritis (PsA) should begin with nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (500mg twice daily) or ibuprofen (400-800mg three times daily) for symptom relief, along with physical therapy to maintain joint function, as recommended by the 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of PsA 1.
Key Considerations
- For patients with persistent symptoms despite NSAIDs, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are recommended, with methotrexate (starting at 7.5-15mg once weekly, potentially increasing to 25mg weekly) being the first-line option, as it is supported by the European League Against Rheumatism (EULAR) recommendations for the treatment of PsA with systemic or local (non-topical) symptomatic and disease-modifying antirheumatic drugs (DMARD) 1.
- Methotrexate should be accompanied by folic acid supplementation (1mg daily) to reduce side effects.
- For patients with inadequate response to methotrexate, other csDMARDs like leflunomide (20mg daily) or sulfasalazine (2-3g daily in divided doses) may be considered.
- In cases of more severe disease or inadequate response to csDMARDs, biologic DMARDs such as TNF inhibitors (adalimumab, etanercept, infliximab) or IL-17 inhibitors (secukinumab, ixekizumab) are recommended, particularly for patients with significant skin involvement, as suggested by the 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of PsA 1.
Treatment Selection
- Treatment selection should be individualized based on disease severity, pattern of joint involvement, presence of skin disease, comorbidities, and patient preferences.
- Early aggressive treatment is crucial to prevent joint damage and disability, as PsA is an inflammatory arthritis that can lead to permanent joint destruction if not adequately controlled.
- The use of a treat-to-target strategy is recommended over not following a treat-to-target strategy, as it is supported by low-quality evidence 1.
From the FDA Drug Label
COSENTYX is indicated for the treatment of active psoriatic arthritis (PsA) in patients 2 years of age and older. The initial treatment approach for patients with psoriatic arthritis (PsA) is not explicitly stated in the provided drug labels.
- The labels mention the indication of secukinumab (SQ) for the treatment of active PsA in patients 2 years of age and older 2, 2.
- However, they do not provide information on the initial treatment approach for PsA. The FDA drug label does not answer the question.
From the Research
Initial Treatment Approach for Psoriatic Arthritis (PsA)
The initial treatment approach for patients with Psoriatic Arthritis (PsA) typically involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions include education, lifestyle changes, physiotherapy, and occupational therapy 3.
- Pharmacological treatments can be divided into two main categories:
- Symptomatic relief: non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage pain and inflammation 3, 4, 5.
- Disease-modifying anti-rheumatic drugs (DMARDs): conventional synthetic DMARDs, such as methotrexate, leflunomide, and sulfasalazine, are used to control the disease process 3, 4, 5.
Treatment Strategies
Treatment strategies for PsA may involve the use of:
- Conventional synthetic DMARDs, such as methotrexate, sulfasalazine, leflunomide, and ciclosporin 4, 5.
- Biologic agents, such as anti-tumor necrosis factor (TNFα), anti-interleukin-17 (IL-17), anti-IL-12/23, and anti-IL-23 agents, as well as Janus kinase (JAK) inhibitors and phosphodiesterase 4 (PDE4) antagonists 3.
- Combination therapy, such as the use of apremilast in combination with biologic agents, may be considered for patients who do not respond adequately to monotherapy 6.
Considerations
When selecting a treatment approach for PsA, it is essential to consider the individual patient's clinical profile, including the presence of comorbidities and the severity of skin and joint involvement 3.
- Biomarkers predictive of response to therapy are needed to allow for a more personalized approach to treatment 3.
- Further research is necessary to address the challenges and unmet needs in the field of PsA, including the development of more effective treatment strategies and the establishment of consensus on accepted treatment withdrawal protocols 7.