For people with mild psoriatic arthritis, taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen, may be enough. These drugs can relieve pain and inflammation, but they don’t change the course of your disease. The next step in psoriatic arthritis treatment is a family of drugs called disease-modifying anti-rheumatic drugs (DMARDs). These drugs, which include methotrexate, sulfasalazine, and leflunomide, impact the entire immune system. Your psoriatic arthritis doctor may prescribe these drugs alone or in combination to help slow down or stop your condition from progressing. A newer addition to the psoriatic arthritis treatment arsenal is a type of DMARD called biologics, which are made from living organisms and proteins to target specific parts of the immune system that cause inflammation in some types of arthritis. Biologics have recently become recommended as a first-line treatment for people living with psoriatic arthritis, according to a recent set of clinical treatment guidelines created by the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF). Despite these recent guidelines, choosing the best treatment for psoriatic arthritis “can be challenging because there are no strict rules,” says Rochella Ostrowski, MD, a rheumatologist and assistant professor of allergy, immunology, and rheumatology at the Loyola University Stritch School of Medicine in Maywood, Illinois. “The best treatment for you may be different than for someone else with the condition.” Still, questions about DMARDs and biologics abound. Here are answers to some of the most common questions people have about psoriatic arthritis treatment:
Why would I need to start taking a DMARD or biologic for psoriatic arthritis?
“If you have a more aggressive form of psoriatic arthritis with multiple-joint involvement or involvement of your spine, the first DMARD to try is usually methotrexate,” Dr. Ostrowski says. If you don’t respond well to this medication or to one of the other traditional DMARDs, your doctor may suggest a biologic therapy. Side effects of methotrexate can include hair loss and mouth ulcers. It can also cause inflammation of the liver, so liver function tests need to be done, according to the NPF. Also, you shouldn’t drink alcohol while taking methotrexate. “Taking the B vitamin folic acid may help prevent some of these side effects,” Ostrowski says.
What if methotrexate isn’t working for my psoriatic arthritis?
If methotrexate doesn’t work for you or if you’re having side effects, your doctor may try prescribing another DMARD or a biologic therapy, according to the NPF. “The dose of methotrexate may be increased over two to three months if it’s tolerated but not effective at a lower dose,” Ostrowski says. “If that doesn’t work, other options would be to try another traditional DMARD or switch to a newer biologic DMARD, such as a TNF inhibitor.”
What other DMARDs are used for psoriatic arthritis?
“Two other DMARDs that might be used before trying a biologic DMARD are leflunomide and sulfasalazine,” Ostrowski says. These are both oral drugs and may take several months to show results. “However, it is not uncommon for doctors to recommend a biologic DMARD over these drugs since they are not usually more effective than methotrexate,” she says. The most common side effect of sulfasalazine is upset stomach. This drug can also increase sensitivity to sunlight, so you’ll need to use a strong sunscreen while taking it. If you’re allergic to any other sulfa drugs, you may not be able to take this drug. Like methotrexate, leflunomide can cause liver injury, and the most common side effect is diarrhea.
When would I need a biologic DMARD for psoriatic arthritis?
“Your doctor may suggest a biologic drug if you have severe disease or you haven’t responded to traditional DMARDs,” Ostrowski says. According to new guidelines for the treatment of psoriatic arthritis developed by the ACR and NPF, biologics should be one of the first line treatments for people with psoriatic arthritis. The British Society for Rheumatology states that a biologic may be considered if you have three or more sore joints despite having tried two or more nonbiologic DMARDs. Another reason to consider a biologic would be that you’ve tried one nonbiologic DMARD but still have five or more sore joints and are developing joint damage. There are several types of biologics for psoriatic arthritis. A type of biologic called a TNF inhibitor targets a protein called tumor necrosis factor alpha (TNF-alpha) that’s associated with psoriasis and psoriatic arthritis. These include:
AdalimumabCertolizumabEtanerceptGolimumabInfliximab
Other biologics interfere with the activity of interleukin-12, interleukin-17, or interleukin-23, proteins associated with inflammation. IL-inhibitors include:
BrodalumabIxekizumabGuselkumabSecukinumabUstekinumab
Another type of biologic interferes with the activation of white blood cells called T cells, which prevents immune system reactions that cause inflammation. Abatacept is the only drug in this class. Dosing of these drugs can vary from a self-administered injection under the skin once a week to once every few months. Another option is an intravenous infusion administered at a medical facility about once every two months.
What else do I need to know about biologics for psoriatic arthritis?
“Biologics are effective, but they increase your risk of infection,” Ostrowski says. If you develop an active infection while taking one of these drugs, you may need to stop treatment until you recover. Similarly, if you have active tuberculosis, hepatitis, or the human immunodeficiency virus (HIV), you will need to get the condition under control before starting biologic treatment. If you’ve recently had cancer, you should discuss this with your rheumatologist and your oncologist before considering biologic treatment, Ostrowski advises. Stay away from unpasteurized milk, raw meat, and raw eggs while taking these drugs to avoid catching a food-borne illness. Also, women with psoriatic arthritis who are considering pregnancy and breastfeeding have additional things to consider. “Many DMARDs, including biologics, cannot be used if you’re pregnant or breastfeeding,” Ostrowski says. If you may become pregnant, you need to discuss taking a biologic drug with your doctor first.
Is there anything else I should discuss with my doctor about DMARDs and biologics for psoriatic arthritis?
There are many options when it comes to psoriatic arthritis treatment. No matter what drug you may be prescribed, ask your doctor or pharmacist about side effects, long-term complications, safety precautions, and drug interactions. In addition, new medications for psoriatic arthritis are always coming onto the market. You should talk to your doctor about whether these medications could be right for your treatment plan. “Which psoriatic treatment you and your doctor choose also depends on how aggressive you need to be,” Ostrowski says. “You need to ask your doctor if you’re getting a more aggressive or conservative treatment. There may be more than one option for the right treatment, but you and your doctor should be on the same page.” Additional reporting by Madeline Vann, MPH and Susan Jara
