19th January 2024

Management

Non-pharmacological management

All patients with suspected psoriatic arthritis should be referred to a rheumatologist for assessment and management. Non-pharmacological therapies include physiotherapy, exercise, and optimization of metabolic risk factors such as smoking cessation and weight loss.

Pharmacological management

In patients with a combination of psoriatic arthritis and psoriasis, monotherapy, which can adequately treat skin and joint disease, is preferred. The European League Against Rheumatism (EULAR) guidelines recommend progression of therapies to achieve adequate disease control and individualised treatment plans.

• Non-steroidal anti-inflammatories (NSAIDs): NSAIDs can be used for symptomatic relief and may even be sufficient for patients with limited disease (i.e., monoarthritis, oligoarthritis and absence of joint erosions). An adequate trial consists of 6-12 weeks of at least 2 NSAIDs. If this does not produce a sufficient improvement in symptoms, other therapies are considered.
• Corticosteroid injections: Intra-articular steroid injections can be used as adjunctive therapy if response to NSAIDs is inadequate. Systemic steroids should be avoided due to the risk of rebound worsening of skin disease once withdrawn.
• Conventional disease-modifying anti-rheumatic drugs (DMARDs): Conventional DMARDs such as Methotrexate, Sulfasalazine or Leflunomide should be considered at an early stage in patients with multiple affected joints, structural damage, raised inflammatory markers and extra-articular manifestations. Methotrexate is often given first line due to ease of administration and rapid onset of action. Hydroxychloroquine should be avoided due to risk of worsening psoriasis. Conventional DMARDs, however, are only used for peripheral arthritis, as they have not been shown to have any benefit in treating axial disease.
• Biological disease-modifying anti-rheumatic drugs (DMARDs): Anti-TNF drugs such as Etanercept, Infliximab, Adalimumab or Golimumab can be offered in patients presenting with arthritis and three or more tender or swollen joints, when at least two other DMARDs have not produced a sufficient response. They are also considered for patients who present with progressive axial disease despite receiving an adequate course of treatment with at least 2 NSAIDs. If there is no response after 12 weeks of receiving a biological agent, treatment should be stopped. Other drugs which can be used if anti-TNF medications are contraindicated include Ustekinumab (human monoclonal antibody which inhibits receptor binding of interleukin 12 and interleukin 23), Secukinumab (monoclonal antibody to interleukin 17) and Apremilast (oral phosphodiesterase-4 inhibitor).

Summary of the management of psoriatic arthritis, adapted from BMJ Best Practice: Psoriatic Arthritis [Internet] Bestpractice.BMJ.com [cited June 2022]. Available from: https://bestpractice.bmj.com/topics/en-gb/524/management-approach