What is the recommended treatment for arthropathic psoriasis?

Treatment of Arthropathic Psoriasis

For arthropathic psoriasis (psoriatic arthritis), TNF inhibitors are recommended as first-line therapy for moderate to severe disease that has failed to respond to at least one DMARD, with methotrexate being the preferred initial DMARD for patients with significant skin involvement. 1

Treatment Algorithm

Step 1: Initial Assessment and First-Line Therapy

• Mild disease:

  • NSAIDs for musculoskeletal symptoms 1
  • Local glucocorticoid injections as adjunctive therapy 1
  • Consider early DMARD initiation if poor prognostic factors are present (structural damage, elevated inflammatory markers, dactylitis, nail involvement) 1

• Moderate to severe disease:

  • Rapidly initiate a conventional synthetic DMARD (csDMARD) 1
  • Methotrexate is preferred, especially with relevant skin involvement 1, 2
  • Alternative csDMARDs: sulfasalazine, leflunomide 1, 2

Step 2: Inadequate Response to Initial Therapy

• If inadequate response to at least one csDMARD, progress to biologic DMARD (bDMARD) therapy 1
• TNF inhibitors (etanercept, infliximab, adalimumab) are equally effective for peripheral arthritis and inhibition of radiographic progression 1
• For patients with significant skin involvement, consider IL-17 inhibitors or IL-12/23 inhibitors 1, 2

Step 3: Inadequate Response to Biologic Therapy

• If inadequate response to a bDMARD, consider:
  • Switching to another bDMARD (including within the same class) 1
  • JAK inhibitor therapy 1
  • For mild disease where bDMARDs or JAK inhibitors are inappropriate, consider PDE4 inhibitor 1

Specific Clinical Manifestations

Peripheral Arthritis

• Polyarticular disease: Rapidly initiate csDMARD, preferably methotrexate 1
• Oligoarticular disease: Consider csDMARD if poor prognostic factors present 1

Axial Disease

• First-line: NSAIDs, physiotherapy, education 1
• If inadequate response: TNF inhibitors 1
• If significant skin involvement with axial disease: Consider IL-17 inhibitor 1

Enthesitis

• Mild: NSAIDs, physical therapy, local corticosteroids 1
• Moderate: DMARDs 1
• Severe or resistant: TNF inhibitors 1

Dactylitis

• Initial: NSAIDs, corticosteroids 1
• Resistant: DMARDs 1
• Refractory: Infliximab has demonstrated efficacy 1

Skin Disease

• Moderate to severe: Consider phototherapy, methotrexate, TNF inhibitors 1
• For significant skin involvement with joint disease: IL-17 or IL-12/23 inhibitors may be preferred 1

Important Considerations

Definition of Treatment Failure

• DMARD failure: Treatment for >3 months with >2 months at standard target dose without adequate response 1
• Intolerance/toxicity: Treatment withdrawal due to side effects 1, 2

Medications to Avoid

• Systemic corticosteroids are not typically recommended due to potential for post-steroid psoriasis flare 1, 2
• Gold salts, chloroquine, and hydroxychloroquine are not recommended 1, 2

Combination Therapy

• Etanercept can be used with or without methotrexate 3
• Research suggests combining methotrexate and etanercept does not significantly improve efficacy over etanercept monotherapy 4
• Apremilast can be safely combined with biologic agents in patients not responding adequately to biologics alone 5

Safety Monitoring

• Prior to initiating TNF inhibitors like etanercept, evaluate for active tuberculosis and test for latent infection 3
• Complete all age-appropriate vaccinations before starting TNF inhibitors 3
• Monitor patients closely for signs of infection during treatment 3

Treatment Target

• Aim for remission or low disease activity through regular disease activity assessment and appropriate therapy adjustment 1
• Consider cautious tapering of DMARDs in patients who achieve sustained remission 1

By following this structured approach to treating arthropathic psoriasis, clinicians can effectively manage both joint and skin manifestations while minimizing disease progression and improving quality of life.