Psoriatic arthritis is a painful, inflammatory condition of the joints that can affect up to 30 percent of patients with psoriasis. The previous post focused on the prevalence, classification, causes, common symptoms, and diagnosis of psoriatic arthritis. This post will delve into the various treatment options available for managing this condition. Usually, a rheumatologist establishes and manages the diagnosis of Psoriatic arthritis, and a dermatologist comanages the skin symptoms of Psoriasis. There is about a 30% chance that patients with skin psoriasis will develop Psoriatic arthritis in the future.
Treatment strategies for psoriatic arthritis and skin psoriasis often address both joint and skin manifestations, considering that some therapies are effective for both joint and skin psoriasis. The primary aim of treatment is to initiate early and aggressive intervention to prevent joint deformity and reduce morbidity. Treatment choices are influenced by the specific pattern of joint involvement, the severity of joint versus skin disease, non-articular involvement, safety considerations related to comorbidities, tolerability, and patient preferences.
Non-pharmacological management plays a crucial role in treating psoriatic arthritis. These strategies include physical and occupational therapy, regular exercise, the use of orthotic devices, and patient education about the disease, joint protection, disease management, and proper medication usage. Additionally, patients should receive support in weight reduction and management of cardiovascular risk factors and other comorbid conditions.
Pharmacological treatment for psoriatic arthritis typically follows a stepwise approach:
Step One:
For patients with mild arthritis limited to a few joints and less severe skin disease, initial treatments focus on managing the skin condition with topical therapies or phototherapy. For joint pain relief, non-steroidal anti-inflammatory drugs (NSAIDs), heat and ice applications, and possibly corticosteroid injections into the affected joints are recommended.
Step Two:
Non-biological disease-modifying antirheumatic drugs (DMARDs) are used to improve symptoms of pain and stiffness. However, while these medications can alleviate symptoms, none have been proven to prevent progressive joint damage, and all carry the risk of serious side effects. Effective DMARDs for joint disease and psoriasis include methotrexate, ciclosporin, leflunomide, and apremilast. Although systemic steroids may help alleviate arthritis symptoms, they often cause a flare-up of psoriasis when the dosage is reduced or discontinued.
Step Three:
Biological DMARDs, particularly TNF-alpha inhibitors, are used for more advanced cases. Biologic response modifiers approved for treating psoriatic arthritis include Adalimumab, Risamkizumab, and Buimekizumab.
Step Four:
Several other agents, either under investigation or currently available, offer additional treatment options. These include abatacept (CTLA4-Ig), a selective T-cell co-stimulation modulator; tofacitinib, a Janus kinase (JAK1 and 3) inhibitor; anti-IL-17 therapies such as secukinumab, brodalumab, and ixekizumab; ustekinumab, a human monoclonal antibody targeting the shared p40 subunit of IL-13 and IL-23; filgotinib, a JAK1 inhibitor; guselkumab, an anti-IL-23 monoclonal antibody; and upadacitinib, another JAK inhibitor.
Step Five:
In certain cases, when joint disease progresses to a severe extent, orthopedic surgery may be required to manage the condition effectively.
These treatment options underscore the importance of a comprehensive and individualized approach to managing psoriatic arthritis, aiming to reduce symptoms, prevent joint damage, and improve the overall quality of life for patients.
