psoriatic%20arthritis
PSORIATIC ARTHRITIS
Psoriatic arthritis is a chronic inflammatory arthropathy associated with cutaneous psoriasis.
It is a progressive disease with asymmetric joint distribution pattern and rheumatoid factor is negative.
It can develop at any time including childhood but most often occurs between 30-50 years old.
Symptoms may range from mild to very severe.

Principles of Therapy

  • Treatment should be initiated once psoriatic arthritis is diagnosed in order to alleviate the manifestations, prevent structural damage, delay disease progression, & maximize the quality of life

Pharmacotherapy

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Provide good short-term symptomatic relief for patients w/ mild psoriatic arthritis
  • Do not inhibit the development of structural joint damage
  • Lowest effective dose of NSAID or COX-2 selective inhibitor should be given for the shortest duration in controlling symptoms due to the potential cardiotoxicity

Corticosteroids

  • Good symptomatic relief for mild psoriatic arthritis but corticosteroids cannot inhibit joint damage
  • Intra-articular corticosteroids are used for persistent synovitis (eg monoarthritis or oligoarthritis) or for bridging therapy while waiting for the systemic treatment to take effect
    • Intra-articular corticosteroids can be used when only a few joints are involved
  • Studies showed no evidence to support the use of systemic corticosteroids in patients w/ peripheral psoriatic arthritis

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

  • Used for patients w/ moderate to severe psoriatic arthritis that is more extensive or aggressive disease, requiring more potent treatment
  • Choice of DMARD should be based on patient preference, severity of joint & skin diseases, efficacy, comorbidities, risks of adverse effects, cost of medication & monitoring
  • DMARD failure is considered if at least 1 DMARD has failed individually or in combination in an adequate therapeutic trial (treatment for ≥3 mth of w/c 2 mth is at standard target dose)

Apremilast

  • A treatment option for patients w/ active psoriatic arthritis
  • Studies have shown that patients showed less joint tenderness & swelling & better physical function while on Apremilast therapy
  • A cyclic adenoside monophosphate (cAMP)-specific phosphodiesterase type-4 (PDE-4) inhibitor that acts by suppressing pro-inflammatory mediators

Methotrexate

  • Primary DMARD in psoriatic arthritis
  • First-line therapy for patients w/ moderate to severe active psoriatic arthritis
  • Effective in treating skin & joint involvement
  • Studies showed reduction in joint swelling, tenderness & erythrocyte sedimentation rate
    • Patients given w/ Methotrexate also showed superior physician assessment of arthritis activity compared to the placebo group

Leflunomide

  • Selectively inhibits pyrimidine synthesis that targets activated T-lymphocytes
  • Recommended for treatment of active peripheral psoriatic arthritis

Sulfasalazine

  • Used as an alternative in treating peripheral psoriatic arthritis
  • Has modest efficacy in patients w/ psoriatic arthritis
  • There were statistically significant positive effects on patient & physician global assessment of disease activity

Cyclosporin

  • May be considered in patients w/ active arthritis unresponsive to at least 2 conventional DMARDs
  • Use is limited because of toxicity issues

Other Disease-Modifying Anti-Rheumatic Drugs

  • Further studies are needed to prove efficacy of gold salts, Azathioprine, & d-Penicillamine for the treatment of psoriatic arthritis

Tumor Necrosis Factor (TNF) Inhibitors

  • Inhibit the pro-inflammatory cytokine involved in inflammation of the skin, synovium & joint fluid
  • Considered also as first-line treatment of moderate to severe active psoriatic arthritis
  • Recommended for treatment of active psoriatic arthritis in patients who are unresponsive or intolerant to at least 2 DMARDs or 1 DMARD w/ poor prognostic factors
  • More expensive compared w/ DMARDs but more cost-effective when used for a long period
  • Provide the following long-term benefits:
    • Decreased need for joint replacement surgery
    • Reduced demands on medical, nursing, & therapy services
    • Reduced needs for other medicines
    • Decreased demands on social services & careers
    • Improved quality of life
    • Increased probability of maintaining work
    • Increased life expectancy
  • TNF inhibitors have equal efficacy & similar adverse reactions
  • Choice of TNF blocker to use is individualized, taking into account the degree & severity of skin involvement
    • Other factors to consider are cost, patient preference, & physician preference 
  • Most clinicians use the combination of TNF inhibitor & Methotrexate as the standard care for the treatment of psoriatic arthritis
  • FDA warns physicians & the public of reports on the occurrence of hepatosplenic T-cell lymphoma, a rare malignancy, in patients receiving TNF inhibitors (eg Adalimumab, Etanercept, Golimumab)

Adalimumab

  • Effective in the treatment of moderate to severe peripheral psoriatic arthritis
  • Studies showed significant benefits such as better response rates, decreased radiographic progression of hand & foot joint disease & improvement in disability

Etanercept

  • Effective in treating moderate to severe peripheral psoriatic arthritis
  • Studies showed improvement in signs & symptoms such as decrease in number of tender joints, swollen joints, & morning stiffness
    • Also noted are decreased C-reactive protein levels, inhibition of radiographic disease progression & better physician & patient global ratings

Golimumab

  • Recommended for the treatment of active & progressive psoriatic arthritis
  • Studies showed statistically significant improvements in joint disease as compared to placebo

Infliximab

  • Effective in moderate to severe peripheral psoriatic arthritis
  • Studies showed better response rates, decreased dactylitis & enthesitis, & inhibition of radiographic disease progression

Ustekinumab

  • A human monoclonal antibody that targets IL-12 & IL-23
  • Recently approved by the FDA for the treatment of adult patients w/ active psoriatic arthritis
  • May be used alone or in combination w/ Methotrexate
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