What is the recommended treatment for psoriatic arthritis?

Treatment for Psoriatic Arthritis

The recommended treatment for psoriatic arthritis follows a stepwise approach, starting with NSAIDs for mild disease, progressing to DMARDs for moderate to severe disease, and advancing to TNF inhibitors for patients who fail to respond to at least one DMARD therapy. 1

Treatment Algorithm Based on Disease Severity

Mild Peripheral Arthritis

• First-line: NSAIDs (Level A evidence) 1

  • Effective for controlling joint symptoms but not skin manifestations
  • Can be used as needed during flares

• Adjunctive therapy: Intra-articular glucocorticoid injections (Level D evidence) 1

  • Use judiciously for persistently inflamed joints
  • Avoid injection through psoriatic plaques
  • Limit repeated injections to the same joint

Moderate to Severe Peripheral Arthritis

• First-line: Disease-modifying antirheumatic drugs (DMARDs) 1, 2

  • Sulfasalazine (Level A evidence)
  • Leflunomide (Level A evidence)
  • Methotrexate (Level B evidence)
  • Ciclosporine (Level B evidence)

• Second-line: TNF inhibitors (Level A evidence) 1, 2

  • For patients who fail to respond to at least one DMARD
  • Options include etanercept, infliximab, adalimumab, certolizumab pegol
  • Consider TNF inhibitors earlier for patients with poor prognosis
  • All currently available TNF inhibitors are equally effective for peripheral arthritis

Axial Disease (Spinal Involvement)

• Mild to Moderate: 1

  • NSAIDs (Level A evidence)
  • Physiotherapy (Level A evidence)
  • Education, analgesia, and injection of sacroiliac joint (Level A evidence)

• Moderate to Severe: 1

  • TNF inhibitors (Level A evidence)
  • Important: Traditional oral DMARDs (methotrexate, leflunomide, sulfasalazine) are NOT effective for axial disease

Enthesitis (Inflammation at Tendon/Ligament Insertion Sites)

• Mild: NSAIDs, physical therapy, corticosteroids (Level D evidence) 1
• Moderate: DMARDs (Level D evidence) 1
• Severe: TNF inhibitors (Level A evidence) 1

Dactylitis (Sausage Digits)

• Initial treatment: NSAIDs (Level D evidence) 1
• Progressive treatment: Corticosteroids (Level D evidence) 1
• Resistant cases: DMARDs (Level D evidence) or Infliximab (Level A evidence) 1

Skin and Nail Involvement

Moderate to Severe Skin Disease

• First-line therapies: 1
  • Phototherapy (UVB/nbUVB, PUVA) (Level A evidence)
  • Methotrexate (Level A evidence)
  • TNF inhibitors (Level A evidence)

Nail Disease

• Treatment options: 1
  • Retinoids (Level C evidence)
  • Oral PUVA (Level C evidence)
  • Ciclosporine (Level C evidence)
  • TNF inhibitors (Level C evidence)

Special Considerations

DMARD Selection and Use

• A DMARD failure is defined as treatment for >3 months with >2 months at standard target dose without adequate response 1
• Intolerance/toxicity is defined as treatment withdrawal due to side effects 1
• Combination therapy with multiple DMARDs may be considered for patients failing monotherapy 1

TNF Inhibitor Administration

• For certolizumab pegol: 400mg initially and at weeks 2 and 4, followed by 200mg every other week or 400mg every 4 weeks 2
• For etanercept: 50mg weekly for adult PsA 3

Important Precautions

• Screen for tuberculosis before initiating TNF inhibitors 3
• Complete all age-appropriate vaccinations before starting therapy 3
• Monitor for serious infections during treatment with biologics 3
• Consider IL-17 or IL-12/23 inhibitors for patients with significant skin involvement 2

Treatment Pitfalls to Avoid

1. Systemic corticosteroids are not typically recommended due to potential for post-steroid psoriasis flare 1
2. Antimalarials may cause progression of skin lesions and are difficult to manage 4
3. Traditional DMARDs are ineffective for axial disease; don't delay TNF inhibitors in these patients 1
4. Gold salts, chloroquine, and hydroxychloroquine are not recommended for PsA 1
5. Aggressive immunosuppression should not follow extensive phototherapy (especially PUVA) due to increased skin cancer risk 1
6. Ciclosporine should be limited to less than 12 consecutive months due to cumulative toxicity concerns 1

By following this evidence-based treatment algorithm and considering the specific manifestations of psoriatic arthritis (peripheral, axial, enthesitis, dactylitis, skin and nail involvement), clinicians can optimize outcomes and improve quality of life for patients with this complex condition.