Treating psoriatic arthritis (PsA) isn't like treating strep throat. You don't just take one medicine for a few days and feel better. PsA is a complex, chronic disease that stays with you and affects many parts of your body -- skin, joints, nails, heart, and lungs.
Many medications slow PsA and relieve symptoms, but the first treatment you try won't always be the right one for you.
"There is no one-size-fits-all, and there is no one medication for psoriatic arthritis," says Saakshi Khattri, MD, assistant professor of dermatology and rheumatology at the Icahn School of Medicine at Mount Sinai in New York. “So often there are patients who do not respond to their medication.”
There are a couple of reasons you might need to switch to a new treatment, says Ethan Craig, MD, assistant professor of clinical medicine at the University of Pennsylvania and rheumatologist at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.
“One is intolerance -- the patient has a side effect of some sort. The second is ineffectiveness. Either the medication doesn't work in the first place, or it works for a period of time and then it stops working," he says.
When your medicine doesn't tame your symptoms, it's time to regroup with your rheumatologist or dermatologist and talk about other treatment options.
Signs That It's Time to Change
The clearest signs that you need a medication switch is a new flare-up of symptoms.
Worsening joint pain and stiffness, increased fatigue, and sudden trouble doing activities that were easy for you are some of the most obvious symptoms. More subtle signs like difficulty sleeping and mood changes also suggest the medication you're on isn't controlling your PsA well enough.
If you've just started on a treatment, you do need to give it time.
Sometimes you can have a partial response -- maybe the swelling comes down in some of your joints but not in others. Then your doctor might suggest that you wait it out for 4 to 6 months to give the drug more time to work. During that time, steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) can help bridge the gap until your medication kicks in.
Once you've been on a treatment for several months with no improvement, or if you're no longer getting relief from a drug you've been taking for a while, "that's often an indication that we need to think about switching things up," Craig says.
Advice for Switching Meds
PsA treatment comes in many forms. Often anti-inflammatories and conventional disease modifying drugs are used (DMARDS). Biologic DMARDS are also often used; they target different pathways in the immune system. There are other options for treatment as well, including targeted synthetic DMARDS and newer oral agents.
Your doctor will take a few factors into consideration when recommending your next step, including:
Your symptoms. PsA causes a variety of symptoms. Your choice of medication may hinge on the type of symptoms you have, how much they bother you, and which drug targets them best.
For example, one of Craig's patients worked at a ticket window. "Because he had to hand out tickets, he was very self-conscious about the appearance of his nails," Craig says. "He was willing to be on a drug that helped his nails, even if it didn't help his arthritis."
The drug’s side effects. Each type of medication comes with a set of side effects, which you need to balance against its benefits. For example, methotrexate can irritate your stomach, while biologics increase the risk for infections. It’s important to think about which side effects you can tolerate and which ones you definitely don't want.
How you take the drug. Many PsA meds come as an infusion or an injection. If you're not a fan of needles, you might prefer a pill.
What other conditions you have. Methotrexate can damage your liver. NSAIDs are linked to heart problems. So if you already have liver or heart disease, these medications may not be safe for you.
Your insurance coverage. Ultimately, your insurance company could decide which treatment you get next. "The sad fact of the matter is that our choice of medication is often substantially constrained by insurance approval," Craig says.
Some insurance companies will expect you to try a certain drug first and prove it doesn't work before they’ll let you switch to the medication that you and your doctor want to use.
How to Ask Your Doctor for a New Treatment
You might already see your doctor every 3 to 4 months if you take medication. During those visits, the doctor can examine your joints, do imaging tests, and check your lab test results to see whether your PsA is under good control.
But tests don’t always tell the whole story. Your point of view is important, too. Let the doctor know if you're having any problems with your medications, including side effects or breakthrough symptoms.
If you're not due for a visit yet, call the office or send your doctor an email about your concerns through the patient portal.
Don’t be afraid to speak up. "A lot of patients are hesitant. They don't want to take up the doctor's time," Craig says. "It's helpful for us if they come in. I hate to see someone suffer for months. And it's often easier to intervene earlier in the course of the disease, when things are less active."
If your doctor isn't on board with you switching medications, don't be afraid to push back to get on the right treatment. "Sometimes it's a matter of miscommunication," he adds. "We need to be on the same page as to what the expectations are, what we're treating, and what effect we expect."
Arthritis Foundation: "Beyond Joints: How Psoriatic Arthritis Affects the Body."
Mayo Clinic: "Psoriatic Arthritis."
Ethan Craig, MD, assistant professor, clinical medicine, University of Pennsylvania, rheumatologist, Corporal Michael J. Crescenz VA Medical Center, Philadelphia.
Saakshi Khattri, MD, assistant professor, dermatology and rheumatology, Icahn School of Medicine at Mount Sinai, New York.