Management of psoriatic arthritis and other peripheral spondyloarthritides

Psoriatic arthritis and other peripheral spondyloarthritides

Non-biological therapies

• consider local corticosteroid injections as monotherapy for non-progressive monoarthritis
  
  
• offer standard disease-modifying anti-rheumatic drugs (DMARDs) to people with:
  
  • peripheral polyarthritis
  • oligoarthritis
  • persistent or progressive monoarthritis associated with peripheral spondyloarthritis
• when deciding which standard DMARD to offer, take into account:
  • the person's needs, preferences and circumstances (such as pregnancy planning and alcohol consumption)
  • comorbidities such as uveitis, psoriasis and inflammatory bowel disease
  • disease characteristics
  • potential side effects
    
    
• if a standard DMARD taken at the maximum tolerated dose for at least 3 months does not provide adequate relief from symptoms, consider switching to or adding another standard DMARD
  
  
• NSAIDs should be considered as an adjunct to standard DMARDs or biological DMARDs to manage symptoms. Use oral NSAIDs at the lowest effective dose for the shortest possible period of time, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  
  
• if NSAIDs do not provide adequate relief from symptoms, consider steroid injections (local or intramuscular) or short-term oral steroid therapy as an adjunct to standard DMARDs or biological DMARDs to manage symptoms
  
  
• if extra-articular disease is adequately controlled by an existing standard DMARD but peripheral spondyloarthritis is not, consider adding another standard DMARD

Targeted synthetic DMARDs – apremilast for the treatment of psoriatic arthritis

• Apremilast, alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is recommended as an option for treating active psoriatic arthritis in adults only if:
• they have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints and
• their disease has not responded to adequate trials of at least 2 standard DMARDs, given either alone or in combination and
• the company provides apremilast with the discount agreed in the patient access scheme.

Biological DMARDs – etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis

• Etanercept, infliximab and adalimumab are recommended for the treatment of adults with active and progressive psoriatic arthritis when the following criteria are met:
  • the person has peripheral arthritis with 3 or more tender joints and 3 or more swollen joints, and
  • the psoriatic arthritis has not responded to adequate trials of at least 2 standard DMARDs, administered either individually or in combination

Biological DMARDs – golimumab for the treatment of psoriatic arthritis

• Golimumab is recommended as an option for the treatment of active and progressive psoriatic arthritis in adults only if it is used as described for other TNF-inhibitor treatments in etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis

Biological DMARDs – ustekinumab for the treatment of psoriatic arthritis

• Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active psoriatic arthritis in adults only when:
  • treatment with TNF-alpha inhibitors is contraindicated but would otherwise be considered, or,
  • the person has had treatment with 1 or more TNF-alpha inhibitors

Other treatment options include (2,3):

• splinting and surgery (on unstable joints) to prevent deformity
• surgery to correct deformity

Systemic steroids should be avoided to prevent the risk of flare up of the skin lesions when the dose is reduced.

Reference:

• NICE (2017). Spondyloarthritis in over 16s: diagnosis and management
• Drug and Therapeutics Bulletin 2006; 44 (1):1-5.
• Arthritis Reasearch Campaign (2009). Hands On - Psoriatic arthritis: its presentation and management in primary care.