What is the recommended treatment for psoriatic arthritis?

Treatment Recommendations for Psoriatic Arthritis

Treatment of psoriatic arthritis should follow a step-wise approach based on disease severity, with NSAIDs for mild disease, DMARDs for moderate to severe disease, and TNF inhibitors for those who fail to respond to at least one DMARD therapy. 1

Initial Assessment and Treatment Stratification

Treatment should be tailored according to the specific manifestations of psoriatic arthritis:

Peripheral Arthritis

• For mild disease:

  • NSAIDs are first-line therapy for symptom control 1
  • Intra-articular glucocorticoid injections for persistently inflamed joints (avoid injection through psoriatic plaques) 1

• For moderate to severe disease:

  • DMARDs should be initiated rapidly 1
  • Preferred DMARDs with level A evidence:
    • Sulfasalazine 1
    • Leflunomide 1
  • Other DMARDs with level B evidence:
    • Methotrexate (preferred when significant skin involvement exists) 1
    • Ciclosporine (limit to <12 months due to cumulative toxicity) 1

• For inadequate response to at least one DMARD:

  • TNF inhibitors (etanercept, infliximab, adalimumab) are recommended 1
  • These agents are equally effective for peripheral arthritis and inhibit radiographic progression 1
  • Patients with poor prognosis may be considered for TNF inhibitors even without DMARD failure 1

Axial Disease

• For mild to moderate axial disease:

  • NSAIDs 1
  • Physiotherapy 1
  • Education, analgesia, and injection of sacroiliac joint 1

• For moderate to severe axial disease:

  • TNF inhibitors are recommended 1
  • Traditional oral DMARDs (methotrexate, leflunomide, sulfasalazine) have not shown efficacy for axial manifestations 1
  • When there is relevant skin involvement, IL-17 inhibitors may be preferred 1

Enthesitis

• For mild enthesitis:
  • NSAIDs, physical therapy, corticosteroids 1
• For moderate enthesitis:
  • DMARDs 1
• For severe enthesitis:
  • TNF inhibitors (evidence for infliximab and etanercept) 1

Dactylitis

• Initial treatment:
  • NSAIDs 1
  • Corticosteroids (many clinicians rapidly progress to injected steroids) 1
• For resistant dactylitis:
  • DMARDs 1
  • Infliximab has shown evidence of efficacy 1

Special Considerations

Skin and Nail Involvement

• For moderate to severe skin disease, consider:
  • Phototherapy (UVB/nbUVB, PUVA) as first-line therapy unless contraindicated 1
  • Methotrexate 1
  • TNF inhibitors 1
  • For nail disease: retinoids, oral PUVA, ciclosporine, or TNF inhibitors 1

Treatment Target and Monitoring

• Treatment should aim at reaching remission or low disease activity 1
• Regular disease activity assessment and appropriate therapy adjustment are essential 1
• Consider factors associated with poor prognosis:
  • Polyarticular disease
  • Elevated ESR
  • Previous treatment failures
  • Existing joint damage
  • Diminished quality of life 1

Medication Cautions

• Systemic corticosteroids should be used with caution at the lowest effective dose due to potential for post-steroid psoriasis flare 1
• Gold salts, chloroquine, and hydroxychloroquine are not recommended 1
• TNF inhibitors carry risks of serious infections and malignancies 2
• Prior to initiating TNF inhibitors:
  • Evaluate for active tuberculosis and test for latent infection
  • Complete all age-appropriate vaccinations 2

Treatment Algorithm

1. Mild peripheral arthritis:

   • Start with NSAIDs 1
   • Add intra-articular glucocorticoid injections for persistent inflammation 1
   • Consider DMARDs if inadequate response 1

2. Moderate to severe peripheral arthritis:

   • Start with DMARDs (sulfasalazine, leflunomide, methotrexate, or ciclosporine) 1
   • Progress to TNF inhibitors if inadequate response to at least one DMARD 1
   • Consider JAK inhibitors if inadequate response to DMARDs and bDMARDs 1

3. Axial disease:

   • Start with NSAIDs and physiotherapy 1
   • Progress to TNF inhibitors if inadequate response 1
   • Consider IL-17 inhibitors if significant skin involvement 1

4. Enthesitis/Dactylitis:

   • Start with NSAIDs and local measures 1
   • Progress to DMARDs for resistant cases 1
   • Consider TNF inhibitors for severe or refractory cases 1

5. For sustained remission:

   • Cautious tapering of DMARDs may be considered 1