Psoriatic arthritis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]
Overview
Pharmacologic therapy for psoriatic arthritis includes nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs, tumor necrosis factor (TNF) inhibitors, and interleukin 17 (IL-17) inhibitors, interleukin IL-12/23 inhibitors, and topical glucocorticoid injections. Psoriatic arthritis is a chronic inflammatory arthritis which is manifested as peripheral and axial arthritis, dactylitis, enthesitis and skin and nail involvement. Non - pharmacologic therapy including patient education, weight reduction, and physical therapy may also play an important role in disease management. While treating the patients the primary goal is to maximize the long-term health-related quality of life.
Medical Therapy
- Medical therapy for psoriatic arthritis is according to the guidelines proposed by
- European League Against Rheumatism (EULAR): Guidelines were first proposed in 2012 and they were updated in 2015.[1][2]
- Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)[3]
- American College of Rheumatology (ACR)
- National Psoriasis Foundation (NPF)
- American Academy of Dermatology (AAD) Psoriasis Guidelines of Care[4]
- British Society of Rheumatology (BSR)[5]
- Pharmacologic therapy for psoriatic arthritis include, non-steroidal anti-inflammatory drugs (NSAIDs), conventional synthetic DMARDs (eg, methotrexate, sulfasalazine, cyclosporin A, leflunomide), biologicDMARDs including, TNF inhibitors (eg, etanercept, infliximab, adalimumab, golimumab), phosphodiesterase (PDE) inhibitors (eg, apremilast), interleukin(IL) inhibitors (eg, secukinumab, ixekizumab, abatacept) and intraarticular glucocorticoid injections.
- Peripheral arthritis:
- Mild disease: Nonsteroidal antiinflammatory drugs (NSAIDs) are the most commonly used drugs for the management of mild active psoriatic arthritis.[6][7]
- Preferred regimen (1): Naproxen: 375-500 mg/twice a day
- Preferred regimen (2): Celecoxib: 200 mg/twice a day
- Preferred regimen (3): Nimesulide: 200 and 400 mg/day
- Preferred regimen (4): Ibuprofen: Max dose of up to 2400 mg/day
- Adverse effects of non-steroidal anti-inflammatory drugs include increased cardiovascular risk, gastritis, ulcers and low renal clearance.
- Moderate to severe disease: Conventional synthetic disease-modifying antirheumatic drugs (DMARDs) may be considered in patients with moderate to severe active peripheral arthritis. These are also considered in patients who are resistant or not responding to NSAIDs, and local corticosteroid injections.
- Preferred regimen (1): Methotrexate[8][9]: 15 to 25 mg/week
- Adverse effects of methotrexate: Liver toxicity, immunosuppression, interstitial pneumonitis, increased infection risk.
- Folic acid supplementation should be given to all patients taking methotrexate.
- Preferred regimen (2): Leflunomide: 20 mg/day
- Adverse effects of Leflunomide: Liver toxicity, diarrhea, rash, alopecia, pneumonitis.
- Preferred regimen (3): Sulfasalazine[9]: 2-3 gms/day
- Adverse effects of sulfasalazine: Nausea, diarrhea, abdominal pain, rash, and neutropenia.
- Preferred regimen (4): Cyclosporine A: 3.5 mg/kg per day[10]
- Preferred regimen (5):Apremilast:[11] It is a phosphodiesterase-4 inhibitor. Dosage: 30 mg twice daily given orally.
- Adeverse effects: Nausea, diarrhea, weight loss, headache.
- Preferred regimen (1): Methotrexate[8][9]: 15 to 25 mg/week
- Severe disease and the presence of adverse prognostic factors: TNF inhibitors (eg, etanercept, infliximab, adalimumab, golimumab), interleukin(IL) inhibitors (eg, secukinumab, ixekizumab, abatacept).
- Biologic DMARDs are considered for patients who fail to respond or contraindication to conventional synthetic DMARDs. It is also administered in patients with presence of poor prognosis factors, even if they have not failed a standard DMARDs therapy.
- TNF inhibitors:
- Preferred regimen (1): Adalimumab[12]: It is a human anti-TNF alpha monoclonal antibody. Dosage: 40 mg can be given s.c every 2 weeks
- Preferred regimen (2): Etanercept[13]: It is a TNF receptor p75-IgG1 fusion protein. Dosage: 50 mg can be given s.c every week.
- Preferred regimen (3): Infliximab[14]: It is a chimeric monoclonal antibody against TNF alpha. Dosage: 5 mg/kg at weeks 0, 2, and 6 and after that 5 mg/kg every 6-8 weeks.
- Preferred regimen (4): Golimumab[15]: it is a human IgG1k anti-TNF alpha antibody. Dosage: 50 mg can be given s.c and monthly.
- Preferred regimen (5): Certolizumab pegol[16]: It is a Fab fragment of anti-TNF alpha monoclonal antibody. Dosage: 400 mg at 0, 2, and 4 weeks can be given s.c and then 200 mg every 2 weeks sub cutaneously.
- Adverse effects: Reactivation of latent tuberculosis, increased risk for infections including bacterial and opportunistic infection. Therefore, before starting treatment with TNF inhibitors screening for TB, Hepatitis B, and C should be done.
- IL inhibitor therapy: This is considered in patients with severe peripheral arthritis, where TNF therapy is contraindicated or not responding even after switching to different TNF inhibitor.
- Anti-IL-17 therapies :
- Preferred regimen (1): Secukinumab[17]: It is a monoclonal antibody against IL-17A. Dosage: 150 mg at weeks 0, 1, 2, 3, and 4 and then every 4 weeks can be given subcutaneously.
- Preferred regimen (2): Ixekizumab[18] : Dosage: 160 mg initially, then 80 mg every two or four weeks can be given subcutaneously.
- Anti-IL-12/23 therapy:
- Ustekinumab[19]: It is a IgG1 monoclonal antibody against the shared P40 subunit of human IL-12 and IL-23. Dosage: 45 mg at weeks 0 and 4 and then for every 12 weeks can be given subcutaneously.
- Anti-IL-17 therapies :
- Abatacept[20]: It is a costimulatory T-cell molecule, blocking signal activation of the CD28 receptor on the T cell inhibiting T-cell activation. Dosage: 125 mg can be given subcutaneously once in a week.
- TNF inhibitors:
- Biologic DMARDs are considered for patients who fail to respond or contraindication to conventional synthetic DMARDs. It is also administered in patients with presence of poor prognosis factors, even if they have not failed a standard DMARDs therapy.
- Mild disease: Nonsteroidal antiinflammatory drugs (NSAIDs) are the most commonly used drugs for the management of mild active psoriatic arthritis.[6][7]
- Axial disease/ spondylitis:[21]
- Mild disease: Non-steroidal anti-inflammatory drugs (NSAIDs), local corticosteroid injections, patient education, exercise and physiotherapy may be recommended to treat mild axial involvement.
- Moderate to severe disease: TNF inhibitors
- Skin disease:[22]
- Phototherapy: First line of treatment including UVB, PUVA.
- Fumeric esters, retinols, calcipotriol
- Conventional DMARDs and TNF inhibitors, and retinoic acid derivatives (eg, acitretin) may be used in combinatination with phototherapy.
- Nail disease:[23]
- Topical corticosteroids, calcipotriol creams, DMARDs and TNF inhibitors may be helpful.
- Enthesitis:
- Mild disease: NSAIDs, local corticosteroid injection, physical therapy may be helpful.
- Moderate to severe disease: TNF inhibitors
- Dactylitis:[24]
- NSAIDs, steroid injections, conventional DMARDs and TNF inhibitors can be helpful.
- Biologic DMARDs can be considered for treatment of dactylitis if, therapy with NSAIDs, steroid injections, conventional DMARDs fails.
- Non pharmacologic therapy:
- Exercise
- Weight reduction
- Physical therapy
- Occupational therapy
- Educating the patient about disease course, joint protection and comorbid conditions.
- Orthotics
References
- ↑ Gossec L, Smolen JS, Ramiro S, de Wit M, Cutolo M, Dougados M, Emery P, Landewé R, Oliver S, Aletaha D, Betteridge N, Braun J, Burmester G, Cañete JD, Damjanov N, FitzGerald O, Haglund E, Helliwell P, Kvien TK, Lories R, Luger T, Maccarone M, Marzo-Ortega H, McGonagle D, McInnes IB, Olivieri I, Pavelka K, Schett G, Sieper J, van den Bosch F, Veale DJ, Wollenhaupt J, Zink A, van der Heijde D (March 2016). "European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update". Ann. Rheum. Dis. 75 (3): 499–510. doi:10.1136/annrheumdis-2015-208337. PMID 26644232.
- ↑ Gossec L, Smolen JS, Gaujoux-Viala C, Ash Z, Marzo-Ortega H, van der Heijde D, FitzGerald O, Aletaha D, Balint P, Boumpas D, Braun J, Breedveld FC, Burmester G, Cañete JD, de Wit M, Dagfinrud H, de Vlam K, Dougados M, Helliwell P, Kavanaugh A, Kvien TK, Landewé R, Luger T, Maccarone M, McGonagle D, McHugh N, McInnes IB, Ritchlin C, Sieper J, Tak PP, Valesini G, Vencovsky J, Winthrop KL, Zink A, Emery P (January 2012). "European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies". Ann. Rheum. Dis. 71 (1): 4–12. doi:10.1136/annrheumdis-2011-200350. PMID 21953336.
- ↑ Ritchlin CT, Kavanaugh A, Gladman DD, Mease PJ, Helliwell P, Boehncke WH, de Vlam K, Fiorentino D, Fitzgerald O, Gottlieb AB, McHugh NJ, Nash P, Qureshi AA, Soriano ER, Taylor WJ (September 2009). "Treatment recommendations for psoriatic arthritis". Ann. Rheum. Dis. 68 (9): 1387–94. doi:10.1136/ard.2008.094946. PMC 2719080. PMID 18952643.
- ↑ Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R (July 2011). "Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions". J. Am. Acad. Dermatol. 65 (1): 137–74. doi:10.1016/j.jaad.2010.11.055. PMID 21306785.
- ↑ Coates LC, Tillett W, Chandler D, Helliwell PS, Korendowych E, Kyle S, McInnes IB, Oliver S, Ormerod A, Smith C, Symmons D, Waldron N, McHugh NJ (October 2013). "The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics". Rheumatology (Oxford). 52 (10): 1754–7. doi:10.1093/rheumatology/ket187. PMID 23887065.
- ↑ Nash P, Clegg DO (March 2005). "Psoriatic arthritis therapy: NSAIDs and traditional DMARDs". Ann. Rheum. Dis. 64 Suppl 2: ii74–7. doi:10.1136/ard.2004.030783. PMC 1766880. PMID 15708943.
- ↑ Sarzi-Puttini P, Santandrea S, Boccassini L, Panni B, Caruso I (2001). "The role of NSAIDs in psoriatic arthritis: evidence from a controlled study with nimesulide". Clin. Exp. Rheumatol. 19 (1 Suppl 22): S17–20. PMID 11296544.
- ↑ Mease P (2013). "Methotrexate in psoriatic arthritis". Bull Hosp Jt Dis (2013). 71 Suppl 1: S41–5. PMID 24219040.
- ↑ 9.0 9.1 Singh YN, Verma KK, Kumar A, Malaviya AN (November 1994). "Methotrexate in psoriatic arthritis". J Assoc Physicians India. 42 (11): 860–2. PMID 7868484.
- ↑ Steinsson K, Jónsdóttir I, Valdimarsson H (August 1990). "Cyclosporin A in psoriatic arthritis: an open study". Ann. Rheum. Dis. 49 (8): 603–6. PMC 1004173. PMID 2396865.
- ↑ Keating GM (March 2017). "Apremilast: A Review in Psoriasis and Psoriatic Arthritis". Drugs. 77 (4): 459–472. doi:10.1007/s40265-017-0709-1. PMID 28213862.
- ↑ Mease PJ, Gladman DD, Ritchlin CT, Ruderman EM, Steinfeld SD, Choy EH, Sharp JT, Ory PA, Perdok RJ, Weinberg MA (October 2005). "Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: results of a double-blind, randomized, placebo-controlled trial". Arthritis Rheum. 52 (10): 3279–89. doi:10.1002/art.21306. PMID 16200601.
- ↑ Mease PJ, Kivitz AJ, Burch FX, Siegel EL, Cohen SB, Ory P, Salonen D, Rubenstein J, Sharp JT, Tsuji W (July 2004). "Etanercept treatment of psoriatic arthritis: safety, efficacy, and effect on disease progression". Arthritis Rheum. 50 (7): 2264–72. doi:10.1002/art.20335. PMID 15248226.
- ↑ Antoni C, Krueger GG, de Vlam K, Birbara C, Beutler A, Guzzo C, Zhou B, Dooley LT, Kavanaugh A (August 2005). "Infliximab improves signs and symptoms of psoriatic arthritis: results of the IMPACT 2 trial". Ann. Rheum. Dis. 64 (8): 1150–7. doi:10.1136/ard.2004.032268. PMC 1755609. PMID 15677701.
- ↑ Kavanaugh A, McInnes I, Mease P, Krueger GG, Gladman D, Gomez-Reino J, Papp K, Zrubek J, Mudivarthy S, Mack M, Visvanathan S, Beutler A (April 2009). "Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four-week efficacy and safety results of a randomized, placebo-controlled study". Arthritis Rheum. 60 (4): 976–86. doi:10.1002/art.24403. PMID 19333944.
- ↑ Mease PJ, Fleischmann R, Deodhar AA, Wollenhaupt J, Khraishi M, Kielar D, Woltering F, Stach C, Hoepken B, Arledge T, van der Heijde D (January 2014). "Effect of certolizumab pegol on signs and symptoms in patients with psoriatic arthritis: 24-week results of a Phase 3 double-blind randomised placebo-controlled study (RAPID-PsA)". Ann. Rheum. Dis. 73 (1): 48–55. doi:10.1136/annrheumdis-2013-203696. PMC 3888622. PMID 23942868.
- ↑ McInnes IB, Mease PJ, Kirkham B, Kavanaugh A, Ritchlin CT, Rahman P, van der Heijde D, Landewé R, Conaghan PG, Gottlieb AB, Richards H, Pricop L, Ligozio G, Patekar M, Mpofu S (September 2015). "Secukinumab, a human anti-interleukin-17A monoclonal antibody, in patients with psoriatic arthritis (FUTURE 2): a randomised, double-blind, placebo-controlled, phase 3 trial". Lancet. 386 (9999): 1137–46. doi:10.1016/S0140-6736(15)61134-5. PMID 26135703.
- ↑ Mease PJ, van der Heijde D, Ritchlin CT, Okada M, Cuchacovich RS, Shuler CL, Lin CY, Braun DK, Lee CH, Gladman DD (January 2017). "Ixekizumab, an interleukin-17A specific monoclonal antibody, for the treatment of biologic-naive patients with active psoriatic arthritis: results from the 24-week randomised, double-blind, placebo-controlled and active (adalimumab)-controlled period of the phase III trial SPIRIT-P1". Ann. Rheum. Dis. 76 (1): 79–87. doi:10.1136/annrheumdis-2016-209709. PMC 5264219. PMID 27553214.
- ↑ McInnes IB, Kavanaugh A, Gottlieb AB, Puig L, Rahman P, Ritchlin C, Brodmerkel C, Li S, Wang Y, Mendelsohn AM, Doyle MK (August 2013). "Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial". Lancet. 382 (9894): 780–9. doi:10.1016/S0140-6736(13)60594-2. PMID 23769296.
- ↑ Mease PJ, Gottlieb AB, van der Heijde D, FitzGerald O, Johnsen A, Nys M, Banerjee S, Gladman DD (September 2017). "Efficacy and safety of abatacept, a T-cell modulator, in a randomised, double-blind, placebo-controlled, phase III study in psoriatic arthritis". Ann. Rheum. Dis. 76 (9): 1550–1558. doi:10.1136/annrheumdis-2016-210724. PMC 5561378. PMID 28473423.
- ↑ Nash P, Lubrano E, Cauli A, Taylor WJ, Olivieri I, Gladman DD (November 2014). "Updated guidelines for the management of axial disease in psoriatic arthritis". J. Rheumatol. 41 (11): 2286–9. doi:10.3899/jrheum.140877. PMID 25362712.
- ↑ Mease PJ, Armstrong AW (March 2014). "Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis". Drugs. 74 (4): 423–41. doi:10.1007/s40265-014-0191-y. PMC 3958815. PMID 24566842.
- ↑ Crowley JJ, Weinberg JM, Wu JJ, Robertson AD, Van Voorhees AS (January 2015). "Treatment of nail psoriasis: best practice recommendations from the Medical Board of the National Psoriasis Foundation". JAMA Dermatol. 151 (1): 87–94. doi:10.1001/jamadermatol.2014.2983. PMID 25471223.
- ↑ Rose S, Toloza S, Bautista-Molano W, Helliwell PS (November 2014). "Comprehensive treatment of dactylitis in psoriatic arthritis". J. Rheumatol. 41 (11): 2295–300. doi:10.3899/jrheum.140879. PMID 25362714.