What is the treatment for psoriatic arthritis?

Treatment for Psoriatic Arthritis

For psoriatic arthritis treatment, a step-wise approach is recommended starting 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 Treatment Based on Disease Severity

Mild Peripheral Arthritis

• NSAIDs are the first-line therapy for symptom control in mild peripheral arthritis 2, 1
• Intra-articular glucocorticoid injections are recommended for persistently inflamed joints (avoid injecting through psoriatic plaques) 2, 1
• If inadequate response to NSAIDs, consider progression to DMARDs 1

Moderate to Severe Peripheral Arthritis

• DMARDs should be initiated rapidly 1
• Preferred DMARDs include:
  • Sulfasalazine and leflunomide (level A evidence) 2, 1
  • Methotrexate when significant skin involvement exists (level B evidence) 2, 1
• TNF inhibitors (etanercept, infliximab, adalimumab) are recommended for inadequate response to at least one DMARD 1, 3
• TNF inhibitors have been shown to inhibit radiographic progression 1, 4

Treatment for Specific Manifestations

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

Enthesitis and Dactylitis

• Initial treatment: NSAIDs and local measures 2, 1
• For resistant cases: DMARDs 2, 1
• For severe or refractory cases: TNF inhibitors 2, 1

Skin and Nail Disease

• For moderate to severe skin disease: consider phototherapy, methotrexate, or TNF inhibitors 1
• For nail disease: retinoids, oral PUVA, ciclosporine, or TNF inhibitors 1

Treatment Failure Considerations

• A patient should be considered a DMARD failure if at least one DMARD has been tried for >3 months, with >2 months at standard target dose 2
• Intolerance/toxicity is defined as treatment withdrawal due to side effects before 2 months of therapy 2
• Factors associated with poor prognosis include:
  • Polyarticular disease (>4 joints affected)
  • Elevated ESR or CRP
  • Previous treatment failures
  • Existing joint damage
  • Diminished quality of life 2, 1

Biologic Therapy Considerations

• Etanercept (Enbrel) is FDA-approved for reducing signs and symptoms, inhibiting structural damage progression, and improving physical function in PsA 3
• Etanercept can be used with or without methotrexate 3
• Recommended dosage for adults with PsA: 50 mg once weekly by subcutaneous injection 3
• Prior to initiating TNF inhibitors, evaluate patients for active tuberculosis and test for latent infection 3
• Complete all age-appropriate vaccinations before starting TNF inhibitor therapy 3
• Monitor patients closely for development of infections during treatment 3

Combination Therapy

• Although evidence for combination therapy is limited, a combination of two or more agents could be used in patients who fail to respond to a single agent or show joint damage progression despite treatment 2
• Etanercept can be initiated in combination with methotrexate or used alone 3

Treatment Goals

• Treatment should aim at reaching remission or low disease activity 1
• Regular disease activity assessment and appropriate therapy adjustment is recommended 1
• Early identification of PsA and early initiation of therapy are important for improving long-term outcomes 2

Bold text indicates the most strongly recommended approach based on current evidence.