What is the best course of treatment for a patient with psoriatic arthritis (PsA) who presents with a gastrointestinal (GI) bleed?

From the Guidelines

For a patient with psoriatic arthritis who presents with a GI bleed, the immediate priority is to address the bleeding while adjusting the PsA treatment regimen. First, discontinue any medications that may contribute to bleeding, particularly NSAIDs and potentially methotrexate 1. The patient should undergo urgent endoscopic evaluation to identify and treat the source of bleeding. Once the bleeding is controlled, consider switching to PsA treatments less likely to affect the GI tract, such as TNF inhibitors (etanercept, certolizumab) or IL-17 inhibitors (secukinumab, ixekizumab) at standard dosing 1. If the patient was previously on oral medications, parenteral routes may be preferred temporarily. For pain management during this transition, acetaminophen (up to 3000mg daily) is safer than NSAIDs. Close monitoring for both GI symptoms and PsA disease activity is essential, with laboratory tests including hemoglobin, iron studies, and inflammatory markers. This approach balances the need to treat the underlying inflammatory arthritis while minimizing GI risks, as untreated PsA can lead to permanent joint damage while certain medications can exacerbate GI bleeding.

Some key considerations in managing PsA with GI bleed include:

• Discontinuing medications that may contribute to bleeding
• Urgent endoscopic evaluation to identify and treat the source of bleeding
• Switching to PsA treatments with lower GI risk, such as TNF inhibitors or IL-17 inhibitors
• Using parenteral routes temporarily if necessary
• Monitoring GI symptoms and PsA disease activity closely

It's also important to consider the patient's overall health and comorbidities when making treatment decisions, as certain medications may have adverse effects or interact with other conditions 1. The most recent guidelines from 2022 provide updated recommendations for the treatment of PsA, including the use of biosimilars and tapering of therapy 1. Overall, a comprehensive approach that takes into account the patient's individual needs and circumstances is essential for effective management of PsA with GI bleed.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Psoriatic Arthritis with GI Bleed

• The treatment of psoriatic arthritis (PsA) typically involves the use of non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), and biologic agents 2, 3, 4, 5, 6.
• However, in the case of a patient with PsA who presents with a gastrointestinal (GI) bleed, the treatment approach may need to be modified to minimize the risk of further GI complications.
• The use of NSAIDs, which are commonly used to treat PsA, may need to be avoided or used with caution in patients with a history of GI bleed, as they can increase the risk of GI toxicity 2, 6.
• In such cases, alternative treatment options such as apremilast, a phosphodiesterase 4 inhibitor, may be considered, as it has been shown to be effective in treating PsA and has a lower risk of GI toxicity compared to NSAIDs 3.
• Biologic agents such as tumor necrosis factor (TNF) inhibitors, which are effective in treating PsA, may also be used with caution in patients with a history of GI bleed, as they can increase the risk of infections and other adverse events 4, 5.
• The treatment approach should be individualized and based on the patient's specific clinical presentation, medical history, and comorbidities, and should involve close monitoring for potential adverse events 2, 3, 4, 5, 6.

Management of GI Bleed in PsA Patients

• The management of GI bleed in patients with PsA requires a multidisciplinary approach, involving rheumatologists, gastroenterologists, and other healthcare professionals 2, 6.
• The treatment of GI bleed should focus on stabilizing the patient, stopping the bleeding, and preventing further complications 6.
• The use of medications such as proton pump inhibitors (PPIs) and histamine-2 (H2) receptor antagonists may be necessary to reduce the risk of GI toxicity and promote healing of the GI mucosa 6.
• In some cases, endoscopic or surgical interventions may be necessary to control the bleeding and prevent further complications 6.

Considerations for Treatment

• When treating a patient with PsA who presents with a GI bleed, it is essential to consider the potential risks and benefits of different treatment options 2, 3, 4, 5, 6.
• The treatment approach should be tailored to the individual patient's needs, taking into account their medical history, comorbidities, and potential contraindications to certain medications 2, 6.
• Close monitoring for potential adverse events, such as GI toxicity, infections, and other complications, is crucial to ensure the safe and effective management of PsA in patients with a history of GI bleed 2, 3, 4, 5, 6.