What is the treatment for psoriatic arthropathy?

Treatment of Psoriatic Arthropathy

The treatment of psoriatic arthropathy should follow a stepwise approach, beginning with NSAIDs for mild disease, progressing to conventional DMARDs (particularly methotrexate), and advancing to TNF inhibitors or other biologics for moderate to severe disease that fails to respond to conventional therapy. 1

Initial Assessment and Classification

• Evaluate disease activity using validated measures:

  • Peripheral joint count
  • Pain assessment
  • Patient global assessment
  • Physical function measurement
  • Quality of life assessment
  • Acute phase reactants (CRP or ESR)

• Poor prognostic factors to identify:

  • Polyarticular disease (vs. oligoarticular)
  • Elevated inflammatory markers
  • Existing joint damage
  • Diminished functional status (HAQ)
  • Reduced quality of life

First-Line Treatment

Mild Disease

• NSAIDs are first-line therapy for mild psoriatic arthropathy with Level A evidence 2, 1
• Local glucocorticoid injections can be used as adjunctive therapy for persistently inflamed joints 2
  • Caution: Avoid injection through psoriatic plaques
  • Limit frequency of injections to the same joint

Important Cautions

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

Second-Line Treatment: Conventional DMARDs

For patients with moderate to severe disease or those who fail to respond to NSAIDs:

• Methotrexate (Level B evidence) - preferred for patients with significant skin involvement 2, 1
• Sulfasalazine (Level A evidence) 2
• Leflunomide (Level A evidence) 2
• Ciclosporin (Level B evidence) - should be limited to less than 12 consecutive months due to cumulative toxicity concerns 2, 1

DMARD Failure Definition

• Treatment for >3 months with >2 months at standard target dose without adequate response 2, 1
• Or intolerance/toxicity defined as treatment withdrawal within 2 months due to adverse effects 2

Third-Line Treatment: Biologics

For patients who fail to respond to at least one DMARD:

• TNF inhibitors (Level A evidence) - etanercept, infliximab, adalimumab 2, 1

  • Infliximab dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3
  • Particularly effective for both joint and skin manifestations
  • Can prevent disease progression and joint damage

• IL-17 inhibitors - consider for patients with significant skin involvement 1

• IL-12/23 inhibitors - consider for patients with concomitant inflammatory bowel disease 1

• JAK inhibitors - can be considered for patients with inadequate response to biologics 1

Special Considerations

Axial Disease (Spinal Involvement)

• NSAIDs and physiotherapy are first-line for mild to moderate axial disease 2
• TNF inhibitors are recommended for moderate to severe axial disease 2
• Traditional DMARDs (methotrexate, sulfasalazine, leflunomide) are not considered effective for axial manifestations 2

Skin Disease

• Phototherapy (UVB/nbUVB, PUVA) is a first-line therapy with Level A evidence 2, 1
• Methotrexate is effective for skin manifestations 2
• TNF inhibitors are effective for both skin and joint manifestations 2, 3

Nail Disease

• Retinoids, oral PUVA, ciclosporin, and TNF inhibitors may be effective 2

Monitoring and Assessment

• Regularly assess disease activity using validated measures:

  • 28-joint Disease Activity Score (DAS28)
  • American College of Rheumatology (ACR) percentage response criteria

• Consider treatment failure if:

  • No acceptable clinical improvement after appropriate duration of therapy
  • Evidence of progression of joint damage on radiographs

Safety Considerations

• TNF inhibitors carry risks of:

  • Serious infections including tuberculosis
  • Malignancies including lymphoma
  • Hepatosplenic T-cell lymphoma (particularly in young males with Crohn's disease or ulcerative colitis on concomitant immunosuppressants)
  • Test for latent TB before starting therapy 3

• Ciclosporin should be limited to less than 12 consecutive months due to cumulative toxicity 2

• Phototherapy should not be followed by aggressive immunosuppression due to increased skin cancer risk 2

The treatment approach should be guided by disease severity, pattern of joint involvement, and presence of extra-articular manifestations, with the goal of achieving remission or low disease activity to prevent joint damage and maintain quality of life.