Because these medications are immunosuppressants, careful monitoring is required in patients to guard against comorbid infection and other side effects.
With a plethora of drug treatments available today, sometimes it’s hard to sift through all the literature and decipher what’s best for your patients with psoriatic arthritis (PsA). If NSAIDs are no longer getting the job done, maybe it’s time to consider disease-modifying antirheumatic drugs (DMARDs).
DMARDs alleviate symptoms like inflammation, pain, and swelling while slowing the progressive joint damage commonly found in patients with psoriatic arthritis. DMARDs are available in biologic and non-biologic forms—and are usually prescribed by specialists.
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) offers guidelines for physicians who treat people with psoriatic arthritis. In addition to useful diagnostic criteria, GRAPPA acknowledges there are several important considerations regarding drug selection: “Many factors influence the choice of DMARD for the individual patient: its relative efficacy, convenience of administration, requirements of the monitoring program, costs of the medication and monitoring.”
Alexis Ogdie, MD, MSCE is a rheumatologist and assistant professor of medicine and epidemiology at the University of Pennsylvania School of Medicine. She ho says DMARDs are intended for “anyone with active psoriatic arthritis, which means swollen and painful joints, or spondylitis, which is inflammation of the spine.”
She says it’s critical that physicians understand how DMARDs work and have a firm grasp on potential complications and side effects—especially since the drugs reduce immune function.
Routine monitoring is important because some people develop “persistent or hard to clear infections,” while taking DMARDs, says Ogdie.
Continuum of care also matters. Primary care physicians, specialists, and support staff can team up and keep closer tabs on patients. Through regular monitoring and maintaining detailed patient records that document treatment changes or new symptoms reported by patients, the entire health care team can provide higher quality patient care with improved quality of life outcomes.
Commonly prescribed non-biologic oral treatments include methotrexate, leflunomide, and sulfasalazine, says Ogdie.
Methotrexate is commonly prescribed to people with rheumatoid arthritis and psoriatic arthritis. It works as an anti-inflammatory and immunosuppressant, and is classified as an antimetabolite cytotoxic agent.
Contraindications with methotrexate include active infection and liver disease. Some people experience hair loss while taking it but supplementing with B-vitamins like folate may help, says Ogdie.
While serious toxicity is sometimes reported, Ogdie says it’s rare. “Most patients don’t have serious toxicity from drugs like methotrexate because they are given in such small doses.”
Some people who take oral DMARDs experience minor side effects such as fatigue, headaches, nausea, or stomach discomfort. But these symptoms may clear within a few weeks, she adds.
Medical experts advise screening for alcohol misuse in people who take some DMARDs like methotrexate and leflunomide.
“You would not prescribe methotrexate to a patient who drinks alcohol regularly or heavily, or if they have pre-existing liver disease,” says Ogdie.
Despite scary stories, “The majority of people do well on these DMARDs,” says Ogdie. She urges physicians to consider “risk benefit ratios” and patient quality of life when prescribing treatments.