How to Achieve Remission in Psoriatic Arthritis

Getting psoriatic arthritis (PsA) under control and achieving remission is possible with currently available medications.

Psoriatic arthritis is a form of inflammatory arthritis that affects both skin and joints. It is treated with conventional disease-modifying antirheumatic drugs (DMARDs) and biologics. In some cases, these medications can lead to a near disappearance of symptoms, prompting patients to wonder if they still need to take them. But remission does not equal cure.

How Can I Reach Remission?

Some people may have a very mild form of PsA and get it under control relatively quickly, whereas others may have very severe disease and have to try several medications and combinations of medications to find relief. There are no clear criteria for defining remission in PsA, so it is difficult to say when you have gotten there. In general, rheumatologists talk about getting to “a minimal disease activity state.”

One of the best ways to help achieve low disease activity is through close collaboration with your rheumatologist. After the initial period they will re-evaluate your symptoms, examine your laboratory findings and then adjust the medication as needed. If you’re not responding adequately, your doctor may change or increase the dose of your medication.

Treat-to-Target Strategy

Some doctors are trying to apply the treat-to-target (T2T) strategy for PsA. Treat-to-target is any strategy where you have a pre-specified management approach to achieve a target outcome that the physician and patient decide is meaningful.

“In T2T, doctors may see patients every 4 weeks with a very clear guideline about how to escalate treatment and change therapy if the patient has not yet reached minimal disease activity. In a ‘usual treatment’ protocol, patients are seen less often, maybe every 12 weeks, and the change in treatment happens based on the preference of the patient and physician at that time. This leads to a slower escalation of therapy compared to T2T strategy, and thus potentially slower achievement of low disease activity, ” says Soumya Reddy, MD, assistant professor of medicine at New York University Langone Medical Center and co-director of its Psoriasis and Psoriatic Arthritis Center. 

Can I Stop My PsA Medication When I Feel Better?

Once you reach a state of low disease activity, rheumatologists recommend you continue on your medications. If you take more than one medication or if your medication comes in different doses, your doctor can try taking you off one medication or lowering the dosage.

“I generally don’t recommend treatment discontinuation for my patients,” says Dr. Reddy. “It’s a common question, but in my experience, most patients will have a recurrence or a flare within a few months of discontinuing medication. For some patients that can be as early as two weeks, but sometimes it can be as late as six months to a year. If patients wish to try stopping the medications after being in a minimal disease activity state for a prolonged period, we work with them and follow them closely during this period. The key is to get them back on medication as soon as they start getting a recurrence.”

Studies show that some patients had a recurrence within six months of stopping medication and most of them flared within the first two to three months. It appears that though the disease may quiet down during remission, it doesn’t cease to exist.

“Although there are some patients that I see who are able to stop medication and go into prolonged periods of remission, it’s not the common scenario,” cautions Dr. Reddy.

Patients who have more consistent, longer duration of disease and patients who have more severe disease are at the highest risk of recurrence. Another risk factor is male gender and evidence of some clinical inflammation on ultrasound.

Can Early Treatment Help Me Achieve Remission?

Starting treatment for psoriatic arthritis as early as possible could, in theory, make lasting remission more likely. Patients with psoriatic arthritis can develop significant damage early in their disease. Unfortunately, many people with psoriasis are unaware they also have PsA, and many patients are undertreated. By treating early, joint damage can be prevented, leading to improved long-term outcomes.

“A patient with PsA for 10 years may have already accumulated some amount of joint damage and possibly deformities limiting the function of their joints. So if you treat them at that point, they may still see significant improvement from treatment, but damage to the joints that has already occurred cannot be reversed,” explains Dr. Reddy.

Although some PsA patients may be frustrated by the need to stay on medication, remission is far better than no remission. One thing to remember is that while these medications work, they don’t cure the disease. However, it is a testament to the effectiveness of current drugs that many patients forget how they felt before, and how affected their joints and skin were prior to being on the medications.