How to manage psoriatic arthritis and/or psoriasis? Quick effective guidance on 3 types of medications

Introduction

Before explaining how to manage psoriatic arthritis? Let us review quickly, psoriatic arthritis is a form of autoimmune joint disease. Either your rheumatologist diagnosed you with it, or my articles “My joints are hurting”, “Some of my joints hurt, what do I have?”, and “I have autoimmune arthritis but which kind(lupus, Rheumatoid, psoriatic…etc)” ; Made you reach this point here.

Typically, whether you have psoriasis and/or psoriatic arthritis, the initial treatment is usually methotrexate and sulfasalazine that I discussed in my Rheumatoid arthritis article. Then depending the medical problems you already have, the choice of biologic is. Also, as I discussed in biologics for Rheumatoid arthritis article, the potential side effect of each medication also guides which treatment to start.

Generally, Rheumatologist are less likely prescribe drugs that works mainly with skin lesions such as skyrizi and aprelimast. The reason is basic, as we typically see the patients with joint issues. Of course, at times I see patients with psoriasis that mainly has osteoarthritis, possibly these 2 articles would help ““My joints are hurting”” and “Some of my joints hurt, what do I have?”.  

Overview on biologics used to treat psoriatic arthritis

Beyond methotrexate, leflunomide, or sulfasalazine, we usually go to biologic drugs. As, I discussed previously, there is some connection between biologics and risk of infection/allergic reaction. Each biologic has pros and cons. I will discuss first those that I start with in sequence. When 1 fails, contraindicated, or causes side effect; then I move to the next one. I will discuss biologics that are generally better with joints first then those better for skin later.   

Main biologics to treat psoriatic arthritis

Humira- is an anti-TNF. As I mentioned in RA article, I do not prescribe if your heart is not pumping normally which docs called reduced ejection fraction.  

Enbrel is also in the category of anti-TNF. It’s way of working is slightly different though, which could lead to higher risk of autoimmune eye disease, therefore it kind of dropped to second.  

For anti-TNF Remicade, Simoni, Simponi aria, and Cimzia, I will refer you to my RA article.  

Obviously, there are more anti-TNF and bio-similar to them.  

Cosyntyx and Taltz IL-17 inhibitors, the issue with this once it has the potential of causing inflammation in the bowel such as ulcerative colitis and Crohn’s disease. Cosyntex comes in infusion form, so your doc might switch you from under the skin injection to infusion to give you a higher dose if medication is working partially as subcutaneous injection. 

Stelara works though affecting IL12/IL23 proteins. This one does not have the issue of causing bowel disease.  

Tremfya which works on IL23, so somewhat similar to Stelara, I generally go to it when patients have recurrent infections from another meds. Also, it is probably a go to medication for patients with prior history of cancer as manufacturer mention that it does not have that increased risk issue.  

Then we could go to Orencia and Actemra which I discussed in RA article.  

Manage psoriasis rather than manage psoriatic arthritis

Now I head towards apremilast (PD4 enzyme inhibitor) and skyrizi(affects IL23 pathway) which from my experience, seem to work better with skin issues. Dermatologist generally prefer these meds as the former is a pill and the latter is once every three months subcutaneous injection. Apremilast is contraindicated in patients with depression, specially those with suicidal ideation. Borth apremilast and skyrizi require liver monitoring by doing blood testing. To be more accurate, apremilast is not a biologic but I keep in this discussion due to somewhat similar side effects profile. Also, discussing the medication does not need a whole article on it.  

Summary

In summary, psoriatic arthritis skin and joint issues are not always active at the same time, therefore the decision is more complex. Also, dermatologist could provide topical treatments or Ultra-violet light therapies that could be effective without biologics for the skin issues. This article serves a general guide to understand some of the choices. Keep in mind, docs generally trust older drugs and insurance companies wants drugs to be longer on the market to trust them. It seems several drug companies are looking at effect of combining biologics drugs. At time of this article, results have not been finalized.