If you have psoriatic arthritis (PsA), your doctor might recommend immunosuppressants, which are medications that calm your immune system. These drugs can be very helpful for managing the joint pain and rashes caused by PsA. But they also can cause serious side effects.
Psoriatic Arthritis and Your Immune System
A healthy immune system protects your body from dangerous germs. But sometimes, your immune system becomes confused and attacks your own cells. When this happens, it is called an autoimmune condition.
PsA is an autoimmune condition where your immune system mistakenly attacks your skin and joints. PsA causes those parts of your body to become inflamed, which means that they become red, swollen, or painful.
Immunosuppressants are drugs that calm down the immune system. They keep your skin and joints from becoming inflamed. Some immunosuppressants, like NSAIDs and corticosteroids, affect the entire immune system. Others just affect specific parts of the immune system.
Doctors often prescribe more than one type of drug to treat PsA. Here are some of the most common immunosuppressants.
Types of Immunosuppressants (and How They Work)
NSAIDs (aspirin, ibuprofen, naproxen). NSAIDs, or nonsteroidal anti-inflammatory drugs, are the first treatment for mild arthritis. They are often sold over the counter but can be prescribed at higher strengths. NSAIDs prevent the body from creating a chemical that causes inflammation throughout your body. They also prevent the creation of a similar molecule that protects your stomach lining from digestive acids. To protect your stomach, only take NSAIDs after eating or with an antacid. NSAIDs usually work within hours.
It is important to remember that NSAIDs lower pain and inflammation, but they don’t prevent PsA from becoming worse.
Corticosteroids (dexamethasone, hydrocortisone, methylprednisolone, prednisone). Corticosteroids, also known as steroids, aren’t the anabolic steroids sometimes misused in sports. Instead, these steroids stop the immune system from making cytokines, which are small proteins that carry messages between immune cells. When these messages are interrupted, the immune system slows down. Steroids also lower the number of certain immune cells, like B and T cells, which help fight off infections.
Steroids are usually used with other medications. For example, they might be prescribed to help with short-term pain relief while you wait for DMARDs to work.
DMARDs. DMARDs (disease-modifying antirheumatic drugs) can lower pain and swelling and help avoid joint damage from PsA. Unlike NSAIDs and steroids, DMARDs can help slow down the disease or keep it from getting worse. There are many types of DMARDs. Most work within 3-6 months.
- Traditional (leflunomide, methotrexate, sulfasalazine). Some DMARDs, like methotrexate, have been used for decades. Methotrexate is the standard treatment for moderate to severe psoriatic arthritis. It helps with scaling skin by slowing down the growth of new cells. Methotrexate is relatively affordable in comparison with similar drugs.
- Azathioprine. This DMARD slows down the growth of new immune cells.
- Biologics (adalimumab, bimekizumab, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, rituximab, secukinumab, tildrakizumab, ustekinumab). Biologics block cytokine messengers that cause inflammation. Each drug focuses on a different kind of cytokine, such as tumor necrosis factors or interleukins.
- Calcineurin inhibitors (cyclosporine). Cyclosporine calms white blood cells in the skin. These cells then can’t make cytokines or more immune cells.
- Hydroxychloroquine. This DMARD was originally used to treat malaria, but doctors realized that it is also helpful for PsA. Doctors aren’t sure how it works, but it seems to interrupt communication between immune cells. It’s often paired with a traditional DMARD.
- Inosine monophosphate dehydrogenase inhibitors (mycophenolate mofetil). Mycophenolate mofetil blocks a protein that is important for creating new immune cells.
- Janus kinase (JAK) inhibitors (baricitinib, tofacitinib, upadacitinib). Like cytokines, JAK proteins help immune cells to communicate. Blocking them slows the spread of inflammation.
- Tyrosine kinase 2 (TYK2) inhibitors (deucravacitinib). TYK2 is a member of the JAK family and works to block the TYK2 protein to slow inflammation.
- Phosphodiesterase inhibitors (apremilast). This drug blocks a protein that causes inflammation.
- Selective costimulation modulators (abatacept). This DMARD calms down T cells, a type of white blood cell.
- Mechanistic target of rapamycin inhibitors. This DMARD interrupts the creation of immune cells called T helper cells. Doctors are still studying whether it can help people with PsA.
Side Effects of Immunosuppressants
If you take immunosuppressants, you should visit the doctor regularly to make sure the treatment is working as it should. Your doctor also will help you to avoid and manage side effects.
NSAIDs can cause stomach pain, ulcers, nausea, diarrhea, allergic reactions, kidney problems, and bruising. Except for aspirin, they can raise your chances for heart attack, stroke, and heart failure, especially if you already have an autoimmune condition like PsA. If you have heart disease, talk to your doctor about whether NSAIDs are safe for you.
Taking steroids for a long time can affect your bones, blood pressure, eyes, and blood sugar. Taking vitamin D and calcium supplements might help with bone heath.
Steroids and DMARDs raise your risk for infections. Talk to your doctor about staying up to date with vaccines and whether you should avoid live vaccines. Wash your hands frequently. Talk with your doctor about whether you should avoid crowded places or certain foods or activities. If you think you are sick (or have nausea, vomiting, rash, or fever), call your doctor right away.
Some DMARDs (including apremilast, cyclosporine, leflunomide, methotrexate, and mycophenolate mofetil) can cause birth defects. Talk to your doctor about taking a break from these drugs before you become pregnant or get someone else pregnant.
Methotrexate, leflunomide, and cyclosporine affect your liver, so talk to your doctor about safe levels of drinking while taking these drugs.
If you take immunosuppressant medication by IV or shot, you might notice swelling, redness, or an itchy rash where the drug enters your body. Antihistamines, corticosteroid creams, or an NSAID can help manage these reactions.
If you are receiving a drug through IV and have any of the following symptoms, stop the treatment and ask the doctor for help:
- Chest pain or tightness
- A hard time breathing
- Fever or chills
- High or low blood pressure
- Swelling of face and hands
Call 911 for any sudden problems with vision, chest pain or tightness, or any trouble breathing.
If you have any of the following symptoms, call your doctor right away:
- Bleeding or bruising easily
- Burning during urination, or urinating more than you usually do
- Chest pain
- Extreme tiredness
- Fever or chills
- Low appetite
- Muscle aches
- New rashes
- Numbness or tingling
- Shortness of breath
- Stomach pain
- Vision problems
- Weight loss
How to Take Immunosuppressants
Immunosuppressants usually are given in a pill, shot, or IV. Different medications have different forms, dosages, and schedules. Ask your doctor about any special instructions, like whether you should take the medicine on a full or empty stomach.
Who Might Take Immunosuppressants (and Who Shouldn’t)
Most people with mild PsA can manage their symptoms with NSAIDs and/or corticosteroids. If these don’t work, your doctor might prescribe a DMARD, usually methotrexate. If methotrexate doesn’t work, you can try other types of DMARDs.
Talk with your doctor before starting or changing any medication. Discuss your health history (especially current infections, other autoimmune conditions, eye problems, kidney or liver disease, heart problems, a history of cancer, or allergies to any drugs) and the drugs and supplements you take.