This overview of NSAIDs, corticosteroids, DMRDs, PDE4 inhibitors, and biologic agents offers recommendations for first-line options for mild and moderate-to-severe psoriatic arthritis.
Drugs for Psoriatic Arthritis. The Medical Letter on Drugs and Therapeutics. 57(1470):e88. June 8, 2015
This overview covers nonselective NSAIDs, corticosteroids, disease-modifying anti-rheumatic drugs (DMRDs), phosphodiesterase type-4 (PDE4) inhibitors, and biologicagents.
The Medical Letter includes wholesale prices of drugs, from $75 or less a month for methotrexate and sulfasalazine to $10,000 or so for most biologics.
At that price, the 5 tumor necrosis factor (TNF) inhibitors, adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab are the most effective treatment available. There are no statistically significant differences among them; all produce ACR 20 responses in the range of 50% to 60%. They reduce joint disease activity, prevent structural damage, and improve function. They also reduce boneerosion more frequently than methotrexate.
The adverse effects include serious infections, particularly in the first 2 to 7 months of treatment. Cancers are reported but causation is not established.
Combination therapy of adding a TNF inhibitor to a DMRD is “controversial,” they conclude.
Ustekinumab had response rates “somewhat lower” than TNF inhibitors, they say, but direct comparisons are lacking. Adverse effects are similar to other biologics.
Secukinumab, in one randomized trial, had more ACR 20 responses than placebo, but the difference didn’t reach statistical significance.
-- For mild psoriatic arthritis, NSAIDs or intra-articular injections of corticosteroids can relieve symptoms.
-- For moderate to severe disease, first-line options include methotrexate, a TNF inhibitor, or a combination of both.