Therapeutic Approaches of Psoriatic Arthritis (PsA)
Non-steroidal anti-inflammatory drugs Glucocorticoids Disease-modifying antirheumatic drugs Important notes on b/tsDMARDs Choice of b/tsDMARD Switching therapy Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drugs (NSAIDs) are useful and frequently used for symptomatic treatment in patients with PsA, particularly those with oligoarthritis, axial disease and enthesitis.
Non-steroidal anti-inflammatory drugs
Disease-modifying antirheumatic drugs
Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs (NSAIDs) are useful and frequently used for symptomatic treatment in patients with PsA, particularly those with oligoarthritis, axial disease and enthesitis. They have no disease-modifying properties in peripheral PsA.[29]
Glucocorticoids
Systemic glucocorticoids (GC) are not advocated for use in PsA. The risk of pustular psoriasis when stopping or tapering systemic corticosteroids is small but well known.[30,31] Intra-articular injections of GC are effective and are generally used for mono- or oligoarticular flares of PsA.[32]
Disease-modifying antirheumatic drugs
Disease-modifying antirheumatic drugs (DMARDs) are divided into three broad groups: conventional synthetic DMARDs (csDMARDs); biologic DMARDs (bDMARDs); and targeted synthetic DMARDs (tsDMARDs).
The csDMARDs to treat PsA include methotrexate (MTX), leflunomide (LEF), and sulfasalazine (SSZ). Antimalarial therapy (chloroquine or hydroxychloroquine) may worsen skin lesions and should be avoided in PsA. The bDMARDs are either biologic original (boDMARDs) or biosimilar (bsDMARDs), and include:
- tumour necrosis factor inhibitors (TNFis): either receptor blockers (etanercept (original and biosimilar)), monoclonal antibodies (infliximab (original and biosimilar)), or adalimumab (original and biosimilar) and golimumab)
- abatacept
- IL-17 inhibitor (IL-17i) (secukinumab and ixekizumab)
- IL-12/23 inhibitors (IL-12/23i) (ustekinumab), and IL-23 inhibitor (IL-23i) (guselkumab).
The tsDMARDs include the Janus kinase inhibitors (JAKis) tofacitinib, and upadacitinib. The phosphodiesterase 5 inhibitor PDE4i (apremilast) also has a place in the therapy of mild PsA.
Important notes on b/tsDMARDs
The use of combination bDMARDs is not recommended.
In SpA (axial or peripheral), there is little evidence that co-prescription of MTX with b/tsDMARDs is necessary.
All b/tsDMARDs should be initiated by a rheumatologist or dermatologist. All patients with a rheumatic disease who are on b/tsDMARDs must be included, with patient consent, in the South African Rheumatism and Arthritis Association (SAARA) biologics registry (https://www.saraa.co.za).
Before commencing b/tsDMARD, appropriate screening and treatment for latent tuberculosis, hepatitis B, hepatitis C and HIV, in addition to vaccination, should be done.
Choice of b/tsDMARD
The b/tsDMARDs may be used in any order. Consideration of patient preference, tuberculosis risk, comorbidities, route of administration and costs is appropriate. There are possible different efficacies with respect to skin and arthritis domains that may influence the rheumatologist’s choice of b/tsDMARD (Table 4[34-36]). In uveitis, monocloncal TNFi therapy is preferred, as the soluble receptor TNFi (etanercept), IL-17i (including sekukinumab and ixekizumab) and JAKi have not been shown to be efficacious. Similarly, the soluble receptor TNFi (etanercept) and IL-17i should not be used in patients with active IBD. For patients with significant skin involvement, preference should be given to MTX/IL-17i/IL-12/23i or IL-23i therapies.
| Table 4. Impact of DMARDs on specific SpA domains | ||||||||
| Condition | csDMARDs | Monoclonal TNFi |
TNF receptor blocker |
IL-17i |
IL-12/ |
IL-23i | JAKi | PDE4i |
| Arthritis | ++ | ++ | ++ | ++ | ++ | ++ | ++ | + |
| Axial disease | - | ++ | ++ | ++ | ? | ? | ++ | - |
| Enthesitis | + | + | + | + | + | ++ | + | + |
| Dactylitis | + | + | + | + | + | ++ | ++ | + |
| Skin | + | ++ | ++ | +++ | +++ | +++ | +/++ | ++ |
| Nail dystrophy | - | ++ | ++ | +++ | +++ | +++ | ++ | + |
| Uveitis | + | ++ | x | x | ? | ? | ? | - |
| IBD | + | ++ | x | x | ++ | ++ |
CD + |
+ |
| DMARD = disease-modifying antirheumatic drug; SpA = spondyloarthritis; csDMARDs = conventional synthetic DMARDs; TNFi = tumour necrosis factor inhibitor; IL-17i = interleukin 17 inhibitor; IL-23i = interleukin-23 inhibitor; IL-12/23i = interleukin 12/23 inhibitor; JAKi = Janus kinase inhibitor; PDE4i = phosphodiesterase-4 inhibitors; + = effective; – = ineffective; × = aggravates; ? = unknown; IBD = inflammatory bowel disease; CD = Crohn’s disease; UC = ulcerative colitis. | ||||||||
Switching therapy
Should the patient have an inadequate response to one b/tsDMARD after 3 months, or toxicity, switching to another is indicated.
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.