Disease-modifying antirheumatic drugs (DMARDs) for psoriatic arthritis
Patients who experience progressive joint destruction in spite of NSAIDs are candidates for more aggressive disease-modifying anti-rheumatic drugs (DMARDs). Disease-modifying medications are important to prevent progressive joint destruction and deformity. These drugs include methotrexate, which is used orally or can be given by injection on a weekly basis for psoriatic arthritis as well as for psoriasis alone. It can cause bone-marrow suppression, as well as liver damage with long-term use. Regular monitoring of blood counts and liver blood tests should be performed during therapy with methotrexate.
Antimalarial medication, such as hydroxychloroquine (Plaquenil), is also used for persistent psoriatic arthritis. Its potential side effects include injury to the retina of the eye. Regular ophthalmologist examinations are suggested while using this medication.
Sulfasalazine (Azulfidine) is an oral sulfa-related medicine that has also been helpful in some patients with persistent psoriatic arthritis. Traditionally, Azulfidine has been an important agent in the medical treatment of ulcerative and Crohn's colitis. It should be taken with food, as it, too, can cause gastrointestinal upset.
Cyclosporine (Gengraf, Neoral, Sandimmune) is another oral medication that can be used to treat psoriatic arthritis. It can be very effective but can cause side effects such as high blood pressure and kidney dysfunction. For this reason, a physician must monitor use very closely.
Medical research has demonstrated effective treatment of both psoriasis and psoriatic arthritis with leflunomide (Arava), a medication that is also used for the treatment of rheumatoid arthritis.
Medications that block the chemical messenger known as tumor necrosis factor (TNF) are another treatment option for moderate to severe psoriatic arthritis. The TNF-blockers etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), and certolizumab pegol (Cimzia) are also referred to as biologic medications and can be very effective for severe psoriatic arthritis. They can significantly improve or eradicate both the psoriasis and the arthritis as well as stop progressive joint damage. These medications are given intravenously or by injections. There is an increased risk of infection while taking biologic medications and patients are screened for underlying tuberculosis prior to TNF-blocker administration.
Ustekinumab (Stelara) is an injectable biologic medication that is used to treat severe plaque psoriasis and psoriatic arthritis with or without methotrexate. This biologic works by blocking chemical messengers called interleukins. There is an increased risk of infections while taking ustekinumab.
Guselkumab (Tremfya) is an injectable biologic that blocks interleukin (IL)-23.
Apremilast (Otezla) is an oral medicine approved for the treatment of patients with moderate to severe plaque psoriasis for whom phototherapy or systemic therapy is appropriate and for the treatment of adult patients with active psoriatic arthritis. Apremilast works by inhibiting an enzyme called phosphodiesterase 4 (PDE4). Apremilast can have side effects, including an increase in depression and gastrointestinal upset such as diarrhea and nausea.
Abatacept (Orencia) is a biologic medication that can be administered either by subcutaneous injection or intravenous injection. It is FDA-approved for the treatment of psoriatic arthritis. Abatacept works by blocking full activation of T cells, which are a main type of cell in the immune system. Inhibiting full T-cell activation decreases arthritic inflammation but may not work well for skin psoriasis.
Secukinumab (Cosentyx) and ixekizumab (Taltz) are injectable biologic medications used to treat adults with psoriatic arthritis. Secukinumab and ixekizumab are antibodies that bind to and block interleukin 17, an important chemical messenger in the inflammation of the skin in psoriasis and the joints in psoriatic arthritis. After a month of weekly loading injections, secukinumab is given monthly or by monthly injections from the start according to the doctor's discretion. Ixekizumab is given as a loading dose and then an injection every 4 weeks. Patients are screened for tuberculosis prior to starting secukinumab or ixekizumab. There is an increased risk for infection when taking these biologic medications. Also, caution is advised in people with Crohn's disease or ulcerative colitis.
Tofacitinib (Xeljanz) is an oral medication that has also been proven to decrease joint inflammation in psoriatic arthritis. Tofacitinib is a JAK-inhibitor medication, which means that it inhibits janus associated kinases. Inhibiting these enzymes decreases the production of a number of different chemical messengers that cause inflammation. There is an increased risk of infection when taking tofacitinib. Patients are screened for underlying tuberculosis prior to starting tofacitinib. Those at risk for colon perforation should discuss this with their physician prior to starting Xeljanz. Caution is also advised in women who may desire a future pregnancy.
Corticosteroids are potent anti-inflammatory agents. Corticosteroids can be given by mouth (such as prednisone) or injected (cortisone) directly into the joints to reduce inflammation. Steroids can have side effects, especially with long-term use. These include thinning of the skin, easy bruising, infections, diabetes, osteoporosis and, rarely, bone death (necrosis) of the hips and knees.
While the relationship between the skin disease and joint disease is not clear, there are reports of improvement of the arthritis simultaneously with clearing of the psoriasis. Patients with psoriasis can benefit by direct sunlight exposure and are often treated with direct ultraviolet light therapy.
Finally, patients who have severe destruction of the joints may be candidates for orthopedic surgical repair. Total hip joint replacement and total knee joint replacement surgery are now commonplace in community hospitals throughout the United States.