What is a high-yield summary of Psoriatic Arthritis (PsA)?

From the Guidelines

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disease that requires early identification and treatment to improve long-term outcomes, with a stepwise approach starting with NSAIDs, followed by conventional DMARDs, and biologics for patients who fail conventional therapy, as recommended by the 2018 American College of Rheumatology/National Psoriasis Foundation guideline 1.

Key Characteristics of PsA

• PsA is associated with psoriasis, manifesting with peripheral arthritis, dactylitis, enthesitis, and spondylitis
• Nail lesions, including pitting and onycholysis, occur in ~80–90% of patients with PsA
• The incidence of PsA is ~6 per 100,000 per year, and the prevalence is ~1–2 per 1,000 in the general population

Treatment Approach

• Treatment follows a stepwise approach starting with NSAIDs like naproxen 500mg twice daily or ibuprofen 800mg three times daily for mild cases
• For moderate disease, conventional DMARDs are used, with methotrexate (starting at 7.5mg weekly, increasing to 15-25mg weekly) being first-line
• In patients who fail conventional therapy, biologics are indicated, including TNF inhibitors (adalimumab 40mg every other week, etanercept 50mg weekly), IL-17 inhibitors (secukinumab 150-300mg monthly), or IL-23 inhibitors (ustekinumab dosed by weight)
• JAK inhibitors like tofacitinib (5mg twice daily) are newer options

Monitoring and Adjustment

• Treatment should address both skin and joint manifestations, with regular monitoring for disease activity and medication side effects
• Physical therapy and lifestyle modifications including weight management and smoking cessation are important adjuncts to pharmacological treatment
• Early diagnosis and treatment are crucial to prevent joint damage and disability, as greater disease activity is associated with progressive joint damage and higher mortality 1

European League Against Rheumatism (EULAR) Recommendations

• The EULAR recommendations for the management of PsA with pharmacological therapies emphasize the importance of a multidisciplinary approach and the use of disease-modifying antirheumatic drugs (DMARDs) and biologics for patients with active disease 1

From the Research

Overview of Psoriatic Arthritis (PsA)

• Psoriatic arthritis is an inflammatory arthritis that affects around 30% of patients with psoriasis 2
• The disease spectrum includes peripheral arthritis, enthesitis, tenosynovitis, dactylitis, axial involvement, and skin and nail psoriasis in most patients 2

Clinical Manifestations and Comorbidities

• PsA can be complicated by several comorbidities, including cardiovascular disease, diabetes mellitus, metabolic syndrome, gout, anxiety, and depression 2
• The management of patients with PsA begins with a careful assessment of the skin and joints and screening for comorbidities 2

Treatment Approaches

• Non-medicinal interventions such as education, lifestyle changes, physiotherapy, and occupational therapy are used in the management of PsA 2
• Pharmacologic treatments include non-steroidal anti-inflammatory drugs, conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), biologic and targeted DMARDs, Janus kinase (JAK) inhibitors, and phosphodiesterase 4 (PDE4) antagonists 2, 3, 4, 5
• Biologic DMARDs (bDMARDs) such as anti-tumor necrosis factor (TNFα), anti-interleukin-17 (IL-17), anti-IL-12/23, and anti-IL-23 agents are used in the treatment of PsA 2, 3, 5, 6

Switching Biologics

• Switching bDMARD therapies is a recommended strategy for patients who experience treatment failure 3
• Many factors must be considered for determining which agent to switch to, including PsA disease characteristics, comorbidities, cardiometabolic risk factors, treatment history, and patient preference 3