What is the initial treatment for psoriatic arthritis?

From the Guidelines

The initial treatment for psoriatic arthritis should be a TNFi biologic, as it has been shown to be more effective than other treatment options, including oral small molecules (OSMs) and IL-17i biologics, in reducing symptoms and improving quality of life 1. When considering the treatment of psoriatic arthritis, it is essential to prioritize the patient's quality of life, morbidity, and mortality. The most recent and highest-quality study, published in 2024, recommends treating patients with polyarthritis or those with monoarthritis/oligoarthritis and poor prognostic factors with a conventional synthetic disease-modifying antirheumatic drug (csDMARD), such as methotrexate, as the first-line treatment 1.

• Key points to consider when treating psoriatic arthritis include:
  • The use of nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve musculoskeletal signs and symptoms
  • The consideration of local injections of glucocorticoids as adjunctive therapy
  • The initiation of a csDMARD, such as methotrexate, in patients with polyarthritis or those with monoarthritis/oligoarthritis and poor prognostic factors
  • The use of a biologic DMARD (bDMARD) in patients who have an inadequate response to at least one csDMARD
• It is crucial to regularly monitor the patient's disease activity and adjust the treatment accordingly to achieve the target of remission or minimal/low disease activity 1. The treatment of psoriatic arthritis should be individualized, taking into account the patient's specific needs and circumstances. By prioritizing the patient's quality of life, morbidity, and mortality, and using the most recent and highest-quality evidence, healthcare providers can provide effective and personalized treatment for patients with psoriatic arthritis.

From the FDA Drug Label

In psoriasis, the rate of production of epithelial cells in the skin is greatly increased over normal skin This differential in proliferation rates is the basis for the use of methotrexate to control the psoriatic process. Methotrexate given weekly at an oral dose of 10 mg/m2 provided significant clinical improvement compared to placebo as measured by either the physician’s global assessment, or by a patient composite (25% reduction in the articular-severity score plus improvement in parent and physician global assessments of disease activity).

The initial treatment for psoriatic arthritis may include methotrexate, as it has been shown to provide significant clinical improvement in patients with this condition 2. The recommended dose is 10 mg/m2 administered orally on a weekly basis. It is essential to closely monitor patients for early signs of toxicity and adjust the dose as needed.

From the Research

Initial Treatment for Psoriatic Arthritis

The initial treatment for psoriatic arthritis typically involves a step-wise approach, starting with nonsteroidal anti-inflammatory drugs (NSAIDs) followed by disease-modifying antirheumatic drugs (DMARDs) and/or tumor necrosis factor (TNF)-α inhibitors and interleukin-12/23p40 inhibitors 3.

Treatment Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as the first line of treatment for psoriatic arthritis 4.
• Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, leflunomide, and ciclosporin are used for the suppression of inflammation in patients with recalcitrant peripheral joint disease 4.
• Tumor necrosis factor inhibitors (TNFi) have emerged as generally well tolerated and highly effective alternatives to traditional disease modifying antirheumatic drugs 5, 6.
• Anti-TNF-α agents, including etanercept, adalimumab, and infliximab, are currently considered as first line biological therapies for the treatment of moderate to severe psoriasis and psoriatic arthritis 3.

Biological Agents

Biological agents, including TNFi, have revolutionized the treatment for moderate to severe plaque psoriasis and psoriatic arthritis 3. The use of biological agents has improved therapeutic outcomes in psoriatic arthritis, with significant clinical efficacy and inhibition of radiographic progression demonstrated by TNFi 6.