What is the initial treatment for psoriatic arthritis?

Initial Treatment for Psoriatic Arthritis

For treatment-naive patients with active psoriatic arthritis, NSAIDs should be initiated first for symptom relief, followed rapidly by methotrexate (or another conventional synthetic DMARD) in patients with polyarthritis, particularly when significant skin involvement is present. 1

First-Line Approach: NSAIDs

• NSAIDs may be used to relieve musculoskeletal signs and symptoms as initial therapy in the vast majority of patients with psoriatic arthritis 1
• NSAIDs provide symptomatic relief for joint pain and stiffness but do not prevent structural joint damage 2
• Cardiovascular and gastrointestinal risks must be considered when prescribing NSAIDs 1
• NSAIDs alone are insufficient for patients with active polyarticular disease or poor prognostic features 1

Rapid Escalation to Disease-Modifying Therapy

For Polyarthritis (Multiple Joint Involvement)

A conventional synthetic DMARD should be initiated rapidly, with methotrexate preferred in those with relevant skin involvement 1

• Methotrexate is the preferred first-line DMARD when both joint and skin disease are present 1
• Alternative conventional synthetic DMARDs include sulfasalazine or leflunomide 1
• Early DMARD initiation (within 3-6 months) is critical to prevent structural damage and preserve joint function 1

For Monoarthritis or Oligoarthritis (Few Joints)

A conventional synthetic DMARD should be considered when poor prognostic factors are present, including: 1

• Structural damage on imaging
• Elevated ESR or CRP
• Dactylitis (sausage digits)
• Nail involvement
• Five or more actively inflamed joints 1

When to Consider Biologics as Initial Therapy

While conventional synthetic DMARDs are standard first-line therapy, TNF inhibitor biologics are preferred over oral small molecules in treatment-naive patients according to the most recent ACR/NPF guidelines 1

However, the EULAR guidelines recommend starting with conventional DMARDs first, reserving biologics for inadequate responders 1. In clinical practice:

• Start with TNF inhibitor if: severe psoriasis is present, severe PsA with multiple poor prognostic factors, or contraindications to methotrexate exist 1
• Start with methotrexate if: moderate disease without severe skin involvement, patient prefers oral therapy, or cost considerations are paramount 1

Adjunctive Therapy

• Local glucocorticoid injections should be considered as adjunctive therapy for individual inflamed joints 1
• Systemic glucocorticoids may be used cautiously at the lowest effective dose, but are not recommended for chronic use due to risk of post-steroid psoriasis flare 1, 3

Critical Monitoring for Methotrexate

Transaminase enzymes must be carefully monitored in patients receiving methotrexate due to increased hepatotoxicity risk in psoriatic arthritis, especially with: 1

• Alcohol consumption
• Obesity
• Type 2 diabetes
• Non-alcoholic steatohepatitis
• Concurrent hepatotoxic medications

Treatment Target and Reassessment

• The goal is remission or, alternatively, low disease activity through regular assessment and appropriate therapy adjustment 1
• Clinical response should be evident within 3-6 weeks for methotrexate 4
• If inadequate response after at least 3 months of DMARD therapy (with >2 months at target dose), escalation to biologic therapy should be considered 1

Common Pitfalls to Avoid

• Do not delay DMARD initiation in patients with polyarthritis or poor prognostic features—NSAIDs alone will not prevent joint damage 1, 2
• Avoid antimalarials (chloroquine, hydroxychloroquine) as they are not recommended in psoriatic arthritis 1
• Do not use chronic systemic corticosteroids due to risk of psoriasis flare upon withdrawal 1
• Screen for tuberculosis, hepatitis B, and hepatitis C before initiating any DMARD or biologic therapy 5, 3