What is the treatment for psoriatic arthritis (PsA)?

From the Guidelines

Treatment of psoriatic arthritis should prioritize a combination of medications to manage both joint inflammation and skin symptoms, with a focus on disease-modifying antirheumatic drugs (DMARDs) and biologics, as recommended by the 2018 American College of Rheumatology/National Psoriasis Foundation guideline 1.

Key Principles of Treatment

• The primary goal of treating patients with psoriatic arthritis is to maximize long-term health-related quality of life, through control of symptoms, prevention of structural damage, normalization of function, and social participation, with abrogation of inflammation being an important component to achieve these goals 1.
• Treatment should be individualized based on disease severity, affected joints, skin involvement, and comorbidities, with regular monitoring for medication effectiveness and side effects.

Medication Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (500mg twice daily) or ibuprofen (400-800mg three times daily) can be used for mild symptoms.
• For moderate to severe disease, DMARDs are recommended, with methotrexate (starting at 7.5-15mg once weekly, potentially increasing to 25mg) being the first-line option, as it can also improve psoriasis 1.
• If methotrexate is ineffective or not tolerated, consider biologics such as TNF inhibitors (adalimumab 40mg every other week, etanercept 50mg weekly), IL-17 inhibitors (secukinumab 150-300mg monthly), or IL-23 inhibitors (ustekinumab 45-90mg every 12 weeks) 1.
• For skin-predominant disease with joint involvement, apremilast (30mg twice daily) may be beneficial.

Additional Therapies

• Corticosteroid injections can provide temporary relief for individual affected joints.
• Physical therapy helps maintain joint function and range of motion.

Treatment Approach

• A treat-to-target strategy may be used, although the specific targets and approach should be individualized based on patient preferences and disease characteristics 1.
• Regular monitoring and adjustment of treatment are crucial to optimize outcomes and minimize side effects.

From the FDA Drug Label

1. 3 Psoriatic Arthritis Enbrel is indicated for reducing signs and symptoms, inhibiting the progression of structural damage of active arthritis, and improving physical function in adult patients with psoriatic arthritis (PsA). Enbrel can be used with or without methotrexate.
2. 3 Recommended Dosage in Adult Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, and Plaque Psoriasis Enbrel is administered by subcutaneous injection (Table 1). Table 1 Recommended Dosage for Adult Patients with RA, AS, PsA and PsO Patient PopulationRecommended Dosage Adult RA, AS, and PsA50 mg weekly

Treatment for Psoriatic Arthritis: Etanercept (Enbrel) is indicated for reducing signs and symptoms, inhibiting the progression of structural damage of active arthritis, and improving physical function in adult patients with psoriatic arthritis (PsA).

• The recommended dosage for adult patients with PsA is 50 mg weekly by subcutaneous injection.
• Etanercept can be used with or without methotrexate 2.

From the Research

Treatment Options for Psoriatic Arthritis

• Non-steroidal anti-inflammatory drugs (NSAIDs) are used as initial treatment for psoriatic arthritis (PsA) to relieve symptoms of joint inflammation 3, 4.
• Disease-modifying anti-rheumatic agents (DMARDs) such as methotrexate, sulfasalazine, leflunomide, and ciclosporin are used to suppress inflammation in patients with recalcitrant peripheral joint disease 3.
• The efficacy of DMARDs in inhibiting joint erosions has not been assessed in controlled studies, and their effectiveness in treating enthesitis and dactylitis is controversial 3.

Specific Treatment Strategies

• Indomethacin, diclofenac, ibuprofen, nimesulide, and celecoxib are some of the NSAIDs that have been evaluated in clinical trials for the treatment of PsA 4.
• Nimesulide and celecoxib have been reported to be significantly more effective than placebo in controlling joint inflammatory-related symptoms in the short-term 4.
• Novel immunomodulatory therapies have been introduced in recent years, raising the bar for treatment and driving research into additional therapeutic options 5.

Considerations for Treatment

• Treatment of PsA should be based on the various manifestations of the disease, including peripheral, axial, enthesitis, dactylitis, as well as skin and nail involvement 3.
• A multidisciplinary approach, including rheumatologists and other healthcare professionals, is necessary to develop effective treatment strategies for PsA 4.