What is the recommended treatment for psoriatic arthritis flares?

Treatment of Psoriatic Arthritis Flares

For psoriatic arthritis flares, the recommended first-line treatment is NSAIDs for mild disease, progressing to conventional DMARDs (particularly methotrexate for significant skin involvement), and advancing to TNF inhibitors or other biologics for moderate to severe disease that fails to respond to conventional therapy. 1

Initial Management of PsA Flares

Mild Disease

• NSAIDs are first-line therapy for mild psoriatic arthritis flares with Level A evidence 1
• Local glucocorticoid injections can be used as adjunctive therapy for persistently inflamed joints
  • Caution: Avoid injection through psoriatic plaques
  • Limit frequency of injections to the same joint 1
• Important caution: Systemic corticosteroids are generally to be avoided in psoriasis as skin disease can flare during or after taper 2
• Potential pitfall: Some NSAIDs (like ibuprofen) may exacerbate psoriatic skin lesions in certain patients 3

Moderate to Severe Disease

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

Conventional DMARDs

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

Treatment for Resistant or Progressive Disease

Biologic Agents

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

1. TNF inhibitors (Level A evidence) 1

   • Etanercept: 50 mg weekly 4
   • Adalimumab: 40 mg every other week 5
   • TNF inhibitors are particularly effective for both joint and skin manifestations 1
   • Can prevent disease progression and joint damage 1

2. For significant skin involvement:

   • Consider IL-17 inhibitors or IL-12/23 inhibitors 1

3. If inadequate response to a biologic DMARD:

   • Consider switching to another biologic DMARD, including within the same class 1
   • JAK inhibitor therapy can be considered for patients with inadequate response to biologic DMARDs 1

Special Considerations for Different PsA Manifestations

Dactylitis Treatment

• Dactylitis (uniform swelling of a digit) occurs in 16-48% of PsA cases and is a clinical indicator of disease severity 2
• Treatment is largely empirical, beginning with NSAIDs and progressing to DMARDs and biologics for resistant cases 2

Axial Disease Treatment

• NSAIDs and physiotherapy are first-line for mild to moderate axial disease 1
• Traditional DMARDs (methotrexate, sulfasalazine, leflunomide) are not considered effective for axial manifestations 1
• TNF inhibitors are recommended for moderate to severe axial disease 1
• For axial disease with significant skin involvement: Consider IL-17 inhibitor 1

Skin Manifestations Treatment

• Methotrexate is effective for skin manifestations 1
• TNF inhibitors are effective for both skin and joint manifestations 1
• For severe skin involvement with arthritis, IL-17 or IL-12/23 inhibitors may be particularly beneficial 1

Safety Considerations

• TNF inhibitors carry risks of serious infections, malignancies, and hepatosplenic T-cell lymphoma 4, 5
• Test patients for latent TB before starting TNF inhibitors 4, 5
• Ciclosporin should be limited to less than 12 consecutive months due to cumulative toxicity 1
• Phototherapy should not be followed by aggressive immunosuppression due to increased skin cancer risk 1

Monitoring Response

• Regularly assess disease activity using validated measures such as the 28-joint Disease Activity Score (DAS28) 1
• Consider treatment failure if there is no acceptable clinical improvement after appropriate duration of therapy or evidence of progression of joint damage on radiographs 1
• DMARD failure is defined as treatment for >3 months with >2 months at standard target dose without adequate response 1

By following this stepwise approach based on disease severity and manifestations, most patients with psoriatic arthritis flares can achieve effective symptom control and prevention of disease progression.