Psoriatic arthritis is a chronic inflammatory joint disease that develops in some people with psoriasis. Psoriasis can affect the joints, skin and nails, skull, spine, fingers, or toes, causing them to become inflamed and painful.

It is a serious condition that can become steadily worse. If left untreated, psoriatic arthritis (PsA) can lead to joint destruction, disability, and impaired quality of life.

Although there is currently no cure for PsA, early diagnosis and targeted treatment plans may slow, or even halt, its progression.

PsA has traditionally been managed using a combination of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying anti-rheumatic drugs (DMARDs).

Recent advances in understanding the body's immune response to PsA has led to new therapies, including the use of tumour necrosis factor inhibitors (TNFs).These have been shown to reduce the progression of joint damage in some patients.

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Drug treatments may control inflammation and relieve discomfort for people with PsA.

The current pharmacological treatment options for PsA aim to:

  • control inflammation
  • relieve discomfort
  • prevent further damage
  • improve quality of life and functional status

NSAIDs

NSAIDs are used to relieve pain and reduce inflammation. They work by blocking the production of compounds known as prostaglandins. These signal the body's immune system to trigger an inflammatory response.

The most common over-the-counter NSAIDs are ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). Stronger NSAIDs are also available by prescription.

Doctors commonly prescribe NSAIDS to people who have mild symptoms of PsA:

  • swelling in fingers or toes
  • swelling where ligaments attach to the bones, including the ribs, spine, and pelvis
  • inflammation of the spinal column

However, NSAIDs increase the risk of heart attack and stroke, bleeding, and kidney problems. People with a history of cardiovascular disease should use NSAIDs with caution.

Corticosteroids

Corticosteroids mimic the anti-inflammatory hormone cortisol, which is normally made by the body's adrenal glands. They are either taken by mouth or administered as a local injection to provide temporary inflammation relief.

However, long-term use can lead to side effects such as facial swelling, weight gain, diabetes, and weak bones.

DMARDs

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DMARDs and biologics, a subtype of DWARDs, work to suppress the overactive immune system but may also raise the risk of infections.

DMARDs, including methotrexate, sulfasalazine, leflunomide, and cyclosporine, are frequently prescribed alongside to NSAIDs.

They help to suppress the body's overactive immune system, which causes persistent inflammation. They can take several weeks to take effect.

A new DMARD, called apremilast (Otezla), was recently approved by both the United States Food and Drug Administration (FDA) and European Medicines Agency (EMA) for the treatment of PsA.

It works by blocking an enzyme that regulates immune and inflammatory processes. Clinical studies suggest that it is effective and generally well-tolerated.

Biologics

Biologics are a special subclass of DMARDs. One group of biologics, known as TNF inhibitors, are typically only offered to people who do not respond effectively to other DMARDs. Examples include:

Biologics work by blocking a specific protein that is produced by immune cells and which signals other cells to start the inflammatory process.

Another biologic, called ustekinumab (Stelara), works by blocking two proteins that cause inflammation. Other biologics block another pro-inflammatory protein

While biologics can be very effective, they suppress the immune system and raise the risk of infections.

Opiods

In certain circumstances your doctor may prescribe opioid analgesics to treat severe cases of PsA. These drugs may assist in the beginning of your PsA treatment, to improve your overall quality of life and set you on the right path towards treatment. This is not a long term solution. These are merely used to improve your quality of life until you find a better way to manage the underlying inflammation.

Management of mild, moderate, and severe PsA

Drug therapyImpact of PsA on quality of life
MildNSAIDs (possibly with local corticosteroid injections)Minimal
ModerateDMARDs or TNF inhibitorsImpacts everyday tasks and physical and mental functions; does not respond to NSAIDs
SevereDMARDs and TNF inhibitorsCannot perform everyday tasks easily without pain; heavy impact on physical and mental functions; does not respond to DMARDs or TNF inhibitors as monotherapy

The following non-drug management strategies are recommended in addition to drug therapy:

  • Exercise: Regular exercise can help to maintain strength in the muscles. Patients should be encouraged to exercise, and referred for physical or occupational therapy where appropriate.
  • Keeping weight down: Obesity and metabolic syndrome are often observed in people with PsA. These conditions are thought to make DMARDs and biologic agents less effective. People with these conditions may benefit from dietary advice and weight loss counselling.
  • Healthful lifestyle: Patients with PsA should be given a set of healthful lifestyle guidelines, which include the need to moderate alcohol intake and not smoke. Appropriate stress management techniques should be discussed where appropriate.
  • Patient education: Patients should be taught about their medications and how to take them properly. They should also be informed about the importance of monitoring the side effects of their medications.

Many people manage their PsA using complementary and alternative medicine (CAM) in addition to conventional treatments. People with PsA should discuss these therapies with healthcare providers before trying them.

Among the most popular are:

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Acupuncture and massage may help relax the muscles and reduce stiffness and pain in the joints.
  • Vitamin and mineral supplements: Doctors often recommend a good multivitamin that includes calcium, folic acid, and vitamin D for people with musculoskeletal disorders. Vitamin D, in particular, has been found to be a strong immune regulator that may benefit people with inflammatory diseases, such as psoriasis.
  • Omega-3 fish oil supplement: A recent study suggests that omega-3 fatty acids also had a beneficial effect on inflammation. The study also noted that people with PsA who took omega-3 fatty acids used less painkillers.
  • Herbal remedies: There is ongoing research that supports the use of turmeric extract - about 1,000 milligrams (mg) per day of curcumin - for relieving the symptoms of joint arthritis.
  • Body treatments: Massage, acupuncture, and acupressure may relax muscles and ease pain and stiffness in the joints.
  • Movement and mind-body therapies: Stress and tension can make symptoms worse. Meditation and yoga, which focus on deep breathing, can help patients to feel more calm and clear-headed.

Special diets

Some people claim that an alkaline diet may reduce inflammation in the body. An alkali diet is one where the focus is on eating alkaline foods, such as whole fruits and vegetables instead of more acidic foods, such as meat and dairy products.

A healthful diet also helps to prevent heart disease, which is a risk factor for people with PsA.

Outlook

Management of PsA usually involves a combination of NSAIDs, corticosteroid injections, or a combination of the two. DMARDs and biologic therapies are prescribed for people with more severe symptoms.

The best choice of therapy will depend upon the disease severity, prior treatment, other conditions that are present, access to therapy, and patient choice.