By Delamo Bekele, MBBS, as told to Alexandra Benisek
With psoriatic arthritis, each person's symptoms and situation are unique. Your rheumatologist will work with you to find a treatment plan that’s tailored to you specifically, rather than a "one-size-fits-all" approach.
Before starting treatment for psoriatic arthritis, doctors do a full evaluation of each patient. We look to see if they have joint involvement, spine involvement, nail or skin disease, and more. Once that’s done, we come up with a medication regimen as well as nondrug ways to target your specific symptoms.
Usually, we start with nonsteroidal anti-inflammatory drugs (NSAIDs) or other anti-inflammatory medications. Then, there's usually some form of immunosuppressive medication – drugs that keep an overactive immune system in check. Finally, we explore treatments like exercise, physical therapy, and weight loss, if needed.
Patient education is also important. Part of that is learning what the goal of treatment is, which is remission, meaning your disease is not active and you have no symptoms.
What Treatments Are Available?
There are several excellent treatments out there. The most powerful are the biologic medications, which include TNF inhibitors as well as other types. There's also oral medication such as methotrexate, one of the standard medications for psoriatic arthritis.
Some people are interested in trying other joint-protective medications that haven't been scientifically proven yet. We can use these in addition to their main medication to control inflammation, but not as the only therapy.
Then there are interleukin-17 (IL-17A) inhibitors; treatments for refractory psoriatic arthritis; and JAK inhibitors, which are oral medications. Newer drugs are also being explored.
Sometimes, patients need additional pain medication. But we try to stay away from opiates. We may prescribe things like duloxetine or tramadol.
How Can You Maximize the Effectiveness of Your Treatment?
What you need to do to make the most of your treatment depends partly on your particular treatment plan. But some basics include:
Keep your doctor updated. Most psoriatic arthritis treatments, other than anti-inflammatory medications, suppress your immune system and can also affect different organs. Let your doctor know any time you start any new medications to make sure there's no interaction.
Also, limit the use of supplements, other drugs, and even alcohol. With certain medications, like methotrexate, you should avoid them completely.
Stay on top of vaccinations. And with COVID-19, try to reduce your risk of exposure. Get vaccinated against specific infections, such as flu and pneumonia, if you're taking a medication that affects your immune system.
Quit smoking. This may not only help your medications work better, but will also improve your cardiovascular health in general.
Weight reduction. If you’re overweight, this is very important. That's not just because it decreases the load on your joints. Excess weight can also mean you don't respond as well to medication. Losing weight reduces your risk of complications from psoriatic arthritis, too.
Your exercise plan should focus on weight loss and strengthening muscles, including your core. We recommend low-impact cardio exercises like walking, cycling, elliptical machines, and pool exercise, especially if you have serious hip, back, or foot pain. Avoid higher-impact activities like running on a treadmill at high speeds or running outdoors. These sometimes make symptoms worse.
Stick to your treatment plan. To get the full benefits, carefully follow your doctor's instructions for your medications. Several studies have shown that if patients don't do this, they don't respond well to treatment. And usually, if you don't respond to treatment at first, it's harder to get your symptoms under control over time.
Keep track of your symptoms. See your doctor regularly, not just a few times a year. Also, assess how you feel every time you check your pain, compared to when your symptoms were at their best.
- Am I stiff in the morning?
- Am I waking up at night with pain?
- Am I getting pain in areas that didn't hurt in the past?
Your answers are signs of whether your treatments are working. If you notice a change, don't wait until your next appointment. Tell your doctor as soon as possible.
Why Some Treatments May Not Work for You
Treatment is different for each person for lots of reasons. It depends first on what you've tried before and how serious your psoriatic arthritis is.
For example, one person's psoriatic arthritis may only involve their left wrist and one finger on their right hand. They might need only a little bit of methotrexate to get it under control. They may go into remission over time and then stop medication altogether.
But another person may have psoriatic arthritis that affects most of the joints in their body. They could go through 10 different medications before finding one that’s effective. We can't do tests to predict which medication will work for a specific patient.
Because of this, it’s important to understand how these medications work and how long it may take for them to work, and to then have follow-ups with your prescribing rheumatologist.
For example, we don’t want to try a medication for a year to see if there are benefits, then try to change your treatment plan. Instead, we want to keep adding medications or making subtle changes until you get to the point where your symptoms are inactive or under control.
If you try a couple of treatments and don't see a response, you’ll work with your rheumatologist and other doctors to find a more comprehensive plan that’s effective.
You may try combination therapy, which means taking more than one medicine at a time. Your doctor might do this if you have very active psoriatic arthritis. But we have to be careful with this approach. Some medications can’t be combined because of the risk of infection. We don't usually combine two different biologic medications.
It’s also important to consider each patient's preferences. You have to inject yourself with some of the medications, so people with needle phobias won't prefer those. If this method isn’t doable, there are a couple of medications you get by infusion (through an IV).
Or a patient may have a busy work schedule, and they're not able to go in for an infusion every couple of weeks. Pills may be better for them.
That's the whole point of tailoring treatment. We have choices, not just based on the science, but also based on what's practical and preferable for each patient.
Photo Credit: daizuoxin / Getty Images
Delamo Bekele, MBBS, rheumatologist, Mayo Clinic, Rochester, MN.