What are the treatment options for a patient with psoriatic arthritis and symptoms of lumbar spinal stenosis or spondylolisthesis?

Treatment Options for Psoriatic Arthritis with Lumbar Spinal Stenosis or Spondylolisthesis

For patients with psoriatic arthritis and symptoms of lumbar spinal stenosis or spondylolisthesis, a combination approach targeting both the inflammatory arthritis and the spinal pathology is required, with TNF inhibitors being the most effective treatment option for moderate to severe disease that has not responded to NSAIDs. 1, 2

Initial Assessment and Treatment Approach

• Disease activity in the spine should be measured using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), with active disease defined as a score >4 3
• Treatment response should be assessed after 6 weeks, with response defined as a BASDAI score <3 or a reduction by 2 points 2
• Treatment should aim to maximize long-term health-related quality of life through control of signs and symptoms, prevention of structural damage, and normalization of function 2

Treatment Algorithm

First-line Treatment for Mild Disease

• NSAIDs at the lowest effective dose with continued evaluation and monitoring 2
  • Provides control of joint symptoms but not skin symptoms 2
  • If the first NSAID is ineffective after 2-4 weeks, another NSAID can be tried 2
• Physical therapy and structured exercise programs 2
• Education and appropriate analgesia 2
• Consider sacroiliac joint injections for localized pain 2, 1

Second-line Treatment for Moderate to Severe Disease

• TNF inhibitors (etanercept, infliximab, adalimumab) are recommended for patients who fail to respond to NSAIDs 2, 1
  • These have demonstrated efficacy in axial disease 2
  • TNF inhibitors are particularly important because traditional DMARDs have not been shown to be effective for axial manifestations of PsA 2, 1

Treatment Considerations for Peripheral Joint Involvement

• For peripheral arthritis accompanying axial disease:
  • Intra-articular glucocorticoid injections for persistently inflamed joints (avoid injection through psoriatic plaques) 2
  • DMARDs for moderate to severe peripheral arthritis 2, 4:
    • Sulfasalazine (Level A evidence) 2
    • Leflunomide (Level A evidence) 2
    • Methotrexate (Level B evidence) - especially when significant skin involvement exists 2, 4
    • Cyclosporine (Level B evidence) 2

Special Considerations

• Traditional oral DMARDs (methotrexate, leflunomide, sulfasalazine) have not been shown to be effective for axial manifestations of PsA and should not be considered adequate for PsA axial disease 2, 1
• If there is relevant skin involvement along with axial disease, an IL-17 inhibitor may be preferred over TNF inhibitors 1
• Treatment should be coordinated between rheumatologists and other specialists (such as dermatologists) when there are significant extra-articular manifestations 2
• Comorbidities such as cardiovascular disease, metabolic syndrome, and depression should be taken into account when managing patients 1

Monitoring and Disease Progression

• Regular monitoring and appropriate adjustment of therapy should aim at reaching remission or low disease activity 2, 1
• Poor prognostic factors include polyarticular disease, elevated inflammatory markers, previous treatment failures, existing joint damage, and diminished quality of life 4, 1
• Uncontrolled arthritis can cause radiologic signs of joint damage in 50% of patients evaluated in tertiary care rheumatology centers 1

Treatment Pitfalls to Avoid

• Delaying initiation of TNF inhibitors in patients with moderate to severe axial disease who have failed NSAIDs 2, 1
• Relying on traditional DMARDs alone for axial disease, as they have not demonstrated efficacy for this manifestation 2, 1
• Failing to assess both peripheral and axial manifestations, as patients may present with various combinations of joint involvement 1
• Not considering skin involvement when selecting therapy, as some agents may be more effective for both skin and joint manifestations 4