Finding the Best PsA Treatment for You

By Linda Rath

Few rheumatic diseases are as challenging to treat as psoriatic arthritis (PsA), mainly because it’s made up of at least five different symptom components. And that doesn’t take into account other conditions that commonly occur with it, such as diabetes, inflammatory bowel disease (IBD) and the eye disorder, uveitis.

“When we’re talking about PsA, we’re talking about multiple things, and some patients respond to certain treatments and others don’t,” notes Susan Goodman, MD, a rheumatologist at Hospital for Special Surgery in New York City.

Another issue: A treatment that might work for one symptom can make others worse. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen ease joint inflammation but can worsen IBD and psoriasis symptoms.

In the end, the key to finding the best treatment plan is doctors and patients working and making decisions together. 

To help you make those decisions, the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF) teamed up in 2018 to publish treatment guidelines. Most recommendations are conditional, meaning: “It depends on an individual’s circumstances.”

Jasvinder Singh, MD, a professor and rheumatologist at the University of Alabama, Birmingham, and lead author of the guidelines, says they are conditional because there are not enough studies to support one drug over another.  

The guidelines recommend a TNF-blocking biologic drug as therapy for people with active PsA who have never been treated or when other treatments haven’t worked. The guidelines also suggest switching to a different TNF blocker if the first one doesn’t work instead of to a different class of drugs.

But there are qualifications. Some patients can’t or don’t want to risk the side effects; others want a pill, not an injection or infusion, and some need a cheaper option. And people with certain conditions or risk factors (i.e., congenital heart failure or recurrent infections) can’t use anti-TNF drugs. In these cases, the treatment options include the conventional DMARD, methotrexate or another biologic, an IL-17 inhibitor.

The use of combination therapies in PsA is not as common as it once was. “There might still be patients who need additional support to get the best response for skin and joints – for example, a steroid cream plus a systemic medication – but I am hoping the use of dual therapies will decrease over time,” says Dr. Singh.

Most doctors will discuss switching therapies if you haven’t seen at least a 20% improvement in symptoms after 12 weeks of treatment.

The ACR/NPF guidelines also strongly recommend nondrug therapies. Dr. Singh says smoking cessation is particularly important and has solid evidence to back it up.

“Smoking cessation is a huge recommendation in our guidelines,” he says. Not only does it improve heart and lung health and reduce the death rate, it can improve PsA disease activity and effectiveness of treatments. “We tell patients who smoke that their medications won’t work as long or as well,” says Dr. Singh. “If you explain to patients how important it is, they usually can do it.”

Weight loss and exercise are the other two main nondrug therapies to improve joint health. “Exercise can also have a positive effect on mental health, muscle biology and range of motion,” says Dr. Singh. “Patients usually say, ‘I’m so glad you talked to me about exercise and weight loss. That tells me they’re important.’”

Most of the ACR/NPF recommendations are suggestions only. Options depend on many factors, including age, other health problems and patients themselves. Together with your doctor, you can weigh your options to decide which plan is best for you.

Ask your doctor these questions as you work together to develop a treatment plan for you PsA:

1. Which treatments help both skin and joint symptoms?
2. Will I need to use a topical treatment for my skin in addition to medication for joint pain?
3. What are the side effects of the different options?
4. What do they cost?
5. How long until I see some improvement?
6. How much will I improve based on different time frames (3 months, 6 months, 1 year)?
7. Can I control my symptoms with lifestyle changes only?
8. How much and how often should I exercise?
9. Will an anti-inflammatory diet like the Mediterranean diet help my skin and joints?

Remember, it can take time to find the perfect combination of treatments. In the meantime, keep an open and honest line of communication with your doctor about your treatment goals and preferences. Together, you can work towards creating a treatment plan that fits your lifestyle and gives you the results you desire.