Psoriatic Arthritis Treatment
The most effective way to get psoriatic arthritis inflammation and your symptoms under control is through medications. There are many drugs used to treat PsA, and the ones you’ll use will depend on how severe your symptoms are, or how PsA affects your body.
In some cases, your dermatologist may be the one to prescribe your treatments and check your progress as you take them. But in many cases, your skin doctor will send you to see a rheumatologist. They specialize in treating inflammatory arthritis like PsA.
Treatments and medications for psoriatic arthritis include NSAIDs, glucocorticoids, Methotrexate, other DMARDS like Sulfasalazine (Azulfidine®) and Leflunomide (Arava®), TNFi biologics, other biologics like Ustekinumab (Stelara®), Secukinumab (Cosentyx®), Abatacept (Orencia®), and biosimilars.
NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
NSAIDs are the most common drugs used to treat inflammation, pain, and swelling. These drugs can treat mild arthritis pain, but they won’t help your skin psoriasis outbreaks or nail problems. If your PsA is moderate to severe, you may find that your joint pain, inflammation, or stiffness is controlled by your DMARDs or biologic drug. If you take those drugs, you may not need NSAIDs at all–or only once in a while.
Glucocorticoids are medicines used to reduce inflammation. They may also be called corticosteroids or even “steroids” for short.
Usually, people with mild PsA get steroid injections in the space around the joints that are painful, swollen, or stiff. That’s called an intra-articular injection.
Your doctor might prescribe a short-term course of oral glucocorticoids, such as prednisone (Deltasone®, Orasone®), if you have a severe flare. Otherwise, these medications are usually avoided. Glucocorticoids are used very sparingly and carefully in people with PsA. That’s because they could cause a flare of skin psoriasis. However, your doctor may decide a short course of these drugs are needed at certain times.
Methotrexate (Rheumatrex®, Trexall®)
The most commonly used DMARD for PsA is methotrexate (Rheumatrex®, Trexall®). It’s likely the first drug your doctor will prescribe to treat your disease. Methotrexate can help you get your arthritis under control and help you manage it moving forward.
Other DMARDS (Disease-Modifying Antirheumatic Drugs)
Some people may start with other DMARDs or similar immunosuppressant drugs instead of methotrexate. Your rheumatologist should speak with you about your options, and why one DMARD might be the right choice for your particular disease.
Other DMARDs and other drugs commonly used for psoriatic arthritis are:
- Sulfasalazine (Azulfidine®): Sulfasalazine (Azulfidine) is used to treat PsA, although it was first used to treat inflammatory bowel disease. People with psoriatic arthritis may respond somewhat slowly to azul dine. It may be used alone or in combination with other DMARDs.
- Leflunomide (Arava®): Leflunomide (Arava) is a DMARD approved to treat moderate to severe rheumatoid arthritis, but is sometimes prescribed “off label” to treat PsA. It can lower joint damage and disability. It can also help ease some symptoms, but isn’t effective for skin psoriasis. It may be used alone or in combination with other DMARDs.
Here are some DMARDs that are rarely prescribed for psoriatic arthritis, but may be used in some cases:
- Hydroxychloroquine (Plaquenil®): Most people tolerate hydroxychloroquine (Plaquenil) well. Some side effects include nausea and diarrhea, but they may lessen over time or if you take your pills with food.
- Cyclosporine (Neoral®, Sandimmune®): Cyclosporine is an older drug that was designed to treat patients who’d received an organ transplant. It was used to prevent their body’s immune system from rejecting the new, donated organ. It may be used for PsA treatment in some cases, such as people with severe skin psoriasis or joint inflammation. It’s usually a short-term option, not a drug you would take regularly over time.
- Azathioprine (Imuran®) (used rarely): Azathioprine (Imuran) is one older DMARD that is used very rarely to treat PsA. It can suppress your immune system which can help reduce joint pain and swelling. It may also curb joint damage and disability. It may only offer mild relief for skin psoriasis.
- Apremilast (Otezla®): In addition to the DMARDs approved to treat psoriatic arthritis, there is another, newer oral drug that you might use called apremilast (Otezla®). Apremilast (Otezla) stops inflammation in your cells and helps control your psoriatic arthritis symptoms like tender or swollen joints, as well as skin symptoms. It works by blocking an enzyme called phosphodieasterase-4 that may play a role in psoriatic inflammation. You may take apremilast (Otezla) with methotrexate or other drugs.
Biologics and Biosimilars
Biologics are a newer type of medication produced by living cells. They’re designed to act like the proteins that are already in your body. They target specific areas of your immune system. Because they’re so specific, they can cause fewer side effects than DMARDs.
Below are the TNFi biologics used to treat psoriatic arthritis. These biologics are molecules that are specially designed to target TNF and block it at the source. They can cool down your immune response that’s out of control in PsA. Some common TNFi biologics are:
- Adalimumab (Humira®)
- Certolizumab pegol (Cimzia®)
- Etanercept (Enbrel®)
- Golimumab (Simponi®, Simponi Aria®)
- Infliximab (Remicade®)
Other Biologic Drugs
There are other biologics that target the immune system in different ways from TNFi drugs. They block certain cytokines, proteins that are involved in PsA inflammation and disease activity.
Normally, cytokines are made by your body’s immune system to fight off infections. But in PsA, they may be out of control. They attack your own tissues by mistake and cause inflammation.
There are biologic drugs can suppress these cytokines. They slow down your immune system, ease inflammation, stop PsA’s progress, and ease your symptoms. Below are these other biologic drugs for PsA:
As we talked about earlier, there are some new drugs called biosimilars that your rheumatologist could prescribe for your psoriatic arthritis. They are highly similar to the original biologic drugs that they were designed to mimic. Currently, there are four biosimilars to biologic drugs that are approved for PsA:
- Adalimumab-atto (Amjevita®)
- Etanercept-szzs (Erelzi®)
- Infliximab-dyyb (Inflectra®)
- Infliximab-abda (Renflexis®)
Janus Kinase (JAK) Inhibitors
JAK inhibitors are a new class of arthritis drugs that treat PsA. They’re not biologics. They are known as small molecule medications.
JAK inhibitors come in pill form. They decrease your immune system’s ability to make certain enzymes that can lead to PsA symptoms. The first JAK inhibitor is tofacitinib (Xeljanz®). Tofacitinib (Xeljanz) works by decreasing the effectiveness of the immune system to reduce pain, swelling, and inflammation. Many others JAK inhibitors are being developed now, and may be approved soon.
JAK inhibitors can be used with or without methotrexate. Your rheumatologist may even prescribe this drug before you try a biologic if he or she thinks it’s the right option for you.
No two people with psoriatic arthritis have the same symptoms. Some people may have very mild skin psoriasis— scaly rashes that flake off and leave your skin feeling raw—and mostly need to focus on treating their joint pain and swelling. Others may have more widespread or severe skin problems. Phototherapy is not used to treat psoriatic arthritis, and you should not try to use sunlight or sunlamps to treat your skin on your own.
If you have PsA, you may have twice the normal risk for getting an infection like the flu, pneumonia or shingles. Why the high risk? Both your disease and the drugs you take that lower your immune system’s activity take a toll on your body’s ability to fight off infection.
The National Psoriasis Foundation’s Medical Board recommends that you get the pneumococcal vaccine before you’ve started systemic therapy for your disease, preceded by the PPSV23 (Pneumovax®) vaccination. If you’re already on systemic therapy, they recommend that you get the PCV13 (Prevnar®) first, followed by the PPSV23 vaccine.
Don’t get any vaccines, even flu or shingles shots, at your local pharmacy without letting your rheumatologist know first.