Psoriatic Arthritis Treatment Recommendations

Managing Joint and Skin Aspects of Psoriatic Arthritis

Psoriatic arthritis
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Psoriatic arthritis is a chronic type of inflammatory arthritis which is associated with psoriasis, a skin disease. Symptoms of joint inflammation and psoriasis often do not occur simultaneously, though. In most psoriatic arthritis patients, symptoms of psoriasis develop prior to arthritis symptoms. However, in about 15 percent of cases, symptoms of arthritis develop before psoriasis appears. In another 15 percent of patients, psoriatic arthritis is diagnosed at the same time as psoriasis.

There are 5 types of psoriatic arthritis: symmetric, asymmetric, distal interphalangeal predominant, spondylitis and arthritis mutilans. Early diagnosis and treatment are important in order to reduce the risk of permanent joint damage. Treatment is geared towards controlling inflammation, and with joint and skin aspects of the disease, both must be addressed.

A task force for EULAR (European League Against Rheumatism) performed an extensive systematic review of scientific literature to evaluate pharmacological treatment of psoriatic arthritis. Originally, EULAR published recommendations in 2012. But by 2015, an update was already needed due to new evidence and the availability of new drugs. In 2012, there were two categories of DMARDs (disease-modifying anti-rheumatic drugs): conventional synthetic DMARDs (abbreviated csDMARDs), which include methotrexate, Arava (leflunomide), Azulfidine (sulfasalazine) and biologic DMARDs (abbreviated bDMARDs).

By 2015, the update included a third category of DMARDs, called targeted synthetic DMARDs (abbreviated tsDMARDs), which include PDE (phosphodiesterase inhibitors) and JAK inhibitors (e.g., Xeljanz [tofacitinib]). The updated guidelines from EULAR include 10 recommendations and 5 overarching principles for the treatment of psoriatic arthritis.

The Overarching Principles

  • Psoriatic arthritis is a heterogeneous (i.e., consists of different aspects) and potentially severe disease which may require multidisciplinary treatment.
  • Psoriatic arthritis treatment should aim at the best care and must be based on a shared decision between the patient and rheumatologist, considering effectiveness, safety, and cost of treatment.
  • Rheumatologists are the specialists who should primarily care for the musculoskeletal aspects of psoriatic arthritis. With the presence of skin involvement, a rheumatologist and a dermatologist should collaborate on diagnosis and disease management.
  • The primary goal of psoriatic arthritis treatment is to maximize health-related quality of life, accomplished through control of symptoms, prevention of structural damage, as well as maintaining normal function and social participation. Reducing inflammation is essential to achieving the goals.
  • Management of the psoriatic arthritis patient must take into account extra-articular manifestations (i.e., other than joints), metabolic syndrome, cardiovascular disease and other comorbid conditions.

    The Recommendations

    Treatment of psoriatic arthritis should target remission or minimal to low disease activity achieved by regular monitoring and making adjustments to therapy as needed.

    • NSAIDs (nonsteroidal anti-inflammatory drugs) may be used to relieve musculoskeletal signs and symptoms.
    • In patients with peripheral arthritis, especially in those with many swollen joints, joint damage with inflammation, elevated sedimentation rate and CRP, and/or extra-articular manifestations csDMARDs should be considered at an early stage, with methotrexate preferred for patients with skin involvement. 
    • Local injections of corticosteroids should be considered as adjunctive (i.e., additional) therapy. Systemic corticosteroids at the lowest effective dose may be used with caution.
    • In patients with peripheral arthritis who have an inadequate response to at least one csDMARD, treatment with a bDMARD should be initiated. The bDMARD is typically a TNF blocker.
    • In patients with peripheral arthritis who have an inadequate response to at least one csDMARD who cannot use a TNF blocker, bDMARDs that target IL12/23 (e.g., Stelara [ustekinumab]) or IL17 (e.g., secukinumab) may be considered.
    • In patients with peripheral arthritis who have an inadequate response to at least one csDMARD and who cannot use bDMARDs, a tsDMARD may be considered.
    • In patients who have active enthesitis and/or dactylitis (swelling of an entire digit) who have an inadequate response to NSAIDs or local corticosteroids injections, a bDMARD should be considered. A TNF blocker is typically tried first.
    • In patients with active axial disease, who have an inadequate response to NSAIDs, a bDMARD should be considered. A TNF blocker is usually tried first.
    • In patients who fail to respond to a bDMARD, switching to another bDMARD should be considered. Switching between different TNF blockers may be considered appropriate. TNF blockers include: Enbrel (etanercept), Remicade (infliximab), Humira (adalimumab), Simponi (golimumab) and Cimzia (certolizumab pegol).


    European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Annals of the Rheumatic Diseases. Gossec L. et al. 2016;75:499-510 doi:10.1136/annrheumdis-2015-208337

    Patient information: Psoriatic arthritis (Beyond the Basics). UpToDate. Gladman and Ritchlin. Updated 4/9/15.

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