Initial Treatment for Psoriatic Arthritis
For treatment-naive patients with active psoriatic arthritis, start with NSAIDs for symptomatic relief while rapidly initiating a conventional synthetic DMARD—methotrexate is preferred, especially if clinically significant skin involvement is present. 1
First-Line Approach: NSAIDs and Conventional Synthetic DMARDs
NSAIDs for Symptomatic Control
- NSAIDs should be used to relieve musculoskeletal signs and symptoms as initial therapy. 1
- These provide symptomatic relief but do not prevent structural damage or modify disease progression. 2
- Cardiovascular and gastrointestinal risks must be considered when selecting and monitoring NSAID therapy. 3
Rapid Initiation of Conventional Synthetic DMARDs
For patients with polyarthritis (multiple joint involvement), a conventional synthetic DMARD should be initiated rapidly—methotrexate is the preferred agent when relevant skin involvement is present. 1
The specific indications for rapid DMARD initiation include:
- Polyarticular disease (typically ≥5 actively inflamed joints) 1
- Elevated inflammatory markers (ESR/CRP) 1
- Presence of structural damage on imaging 1
- Dactylitis (sausage digits) or nail involvement 1
- Clinically relevant extra-articular manifestations 1
DMARD Selection Strategy
Methotrexate is the first-choice conventional synthetic DMARD, particularly when psoriatic skin disease is clinically significant, as it treats both joint and skin manifestations. 1
Alternative conventional synthetic DMARDs include:
Monoarthritis or Oligoarthritis Considerations
For patients with monoarthritis or oligoarthritis (few joints involved), a conventional synthetic DMARD should be considered if poor prognostic factors are present: 1
If poor prognostic factors are absent in oligoarticular disease, NSAIDs alone with close monitoring may be appropriate initially. 1
Adjunctive Glucocorticoid Therapy
Local intra-articular glucocorticoid injections should be considered as adjunctive therapy for persistently inflamed joints. 1
Systemic glucocorticoids may be used with caution at the lowest effective dose for short-term bridge therapy, but are not recommended for chronic use due to risk of post-steroid psoriasis flare. 1
Treatment Target and Monitoring
Treatment should be aimed at reaching remission or, alternatively, low disease activity through regular disease activity assessment and appropriate therapy adjustment. 1
An adequate trial of a conventional synthetic DMARD is 3-6 months at therapeutic dose before determining inadequate response. 4
When to Escalate Beyond Conventional Therapy
If peripheral arthritis shows inadequate response to at least one conventional synthetic DMARD after an appropriate trial, therapy with a biologic DMARD should be commenced: 1
- TNF inhibitors are the preferred biologic class for most patients 1
- IL-17 inhibitors or IL-12/23 inhibitors may be preferred when there is relevant skin involvement 1
- IL-12/23 inhibitors should be considered if concomitant inflammatory bowel disease is present 5, 3
Critical Pitfalls to Avoid
Do not delay DMARD initiation in patients with polyarticular disease or poor prognostic factors—early intervention prevents irreversible structural damage. 1
Avoid antimalarials (chloroquine, hydroxychloroquine) and gold salts, as these are not recommended for psoriatic arthritis. 1
Do not use NSAIDs as monotherapy in patients with active polyarticular disease, elevated inflammatory markers, or structural damage—these patients require disease-modifying therapy. 1
Systemic corticosteroids should not be used as primary long-term therapy given availability of more effective disease-modifying options and risk of psoriasis flare upon discontinuation. 1, 5
Multidisciplinary Collaboration
Rheumatologists should primarily care for musculoskeletal manifestations; when clinically significant skin involvement is present, collaboration with a dermatologist is essential for optimal management. 1