Details of Therapies for Specific Domains
Peripheral arthritis Axial disease Enthesitis Dactylitis Peripheral arthritis First-line therapy: MTX (7.5 mg - 25 mg weekly). In the case of mono- or oligoarthritis, a good response may be obtained with NSAIDs and/or intra-articular GC. Second-line therapy: addition of/switching to SSZ or LEF is recommended. These may be monotherapy or combination therapy. Third-line therapy: b/tsDMA
Peripheral arthritis
First-line therapy: MTX (7.5 mg - 25 mg weekly). In the case of mono- or oligoarthritis, a good response may be obtained with NSAIDs and/or intra-articular GC.
Second-line therapy: addition of/switching to SSZ or LEF is recommended. These may be monotherapy or combination therapy.
Third-line therapy: b/tsDMARDS.
Axial disease
First-line therapy: NSAIDs. Two courses of at least two different NSAIDs at the maximum recommended doses/maximum tolerated doses over 4 weeks. Importantly, csDMARDs have no proven benefits in axial disease. Intra-articular GC into the sacro-iliac joint(s) can be considered.
Second-line therapy: patients who have an inadequate response to NSAIDs (ASDAS ≥2.1 or BASDAI ≥4) should be considered for b/tsDMARD therapy. The efficacy of IL-12/23i or IL-23i in psoriatic axial disease is unclear.[37-39]
Enthesitis
First-line therapy: NSAIDs. Intralesional corticosteroid injections can be tried, but there is no evidence of benefit. A recent study showed MTX resolved enthesitis in 43.1% of PsA patients.[40] Second-line therapy: b/tsDMARDs.
Dactylitis
First-line therapy: NSAIDs.
Second-line therapy: MTX.
Second-line therapy: b/tsDMARDs
Benitha, R., Maharaj, A. B., Makan, K., Potts, J., Lai, A., Carter, R., van Dam, M., & Hodkinson, B. (2024). South African Rheumatism and Arthritis Association 2024 guidelines for the management of peripheral spondyloarthritis. South African Medical Journal, 114(10), e2669.