Treating Psoriatic Arthritis

Many options are available to treat psoriatic arthritis (PsA), ranging from over-the-counter medicines to highly specialized therapies. Regardless of which is chosen, the overall goal is clear: Doctors seek to relieve pain and swelling, as well as slow down the joint damage associated with the disease, before it affects a patient's ability to function and his or her quality of life.

Dermatologists may be the first physicians to identify psoriatic arthritis because it is so closely related to psoriasis; however, it is often a rheumatologist who will make the decisions about which treatment will work best. Those decisions are generally based on the severity of the disease, the number of joints involved and whether any associated skin symptoms are also present. This approach to treatment must be individualized and requires both patience and perseverance. Patients must remember that what works for one person with psoriatic arthritis may not work for someone else.

Nonsteroidal Anti-inflammatory Drugs are Often the First Line of Defense
During the early stages of the disease, mild inflammation may respond to nonsteroidal anti-inflammatory drugs (NSAIDs) that are available over-the-counter or in stronger doses by prescription. Theses drugs include aspirin, ibuprofen (Advil®, Motrin®) and naproxen (Aleve®, Naprosyn®). These drugs can decrease inflammation, reduce joint pain, and help to alleviate the morning stiffness that is commonly associated with psoriatic arthritis.

Because taking NSAIDs in high doses or for extended periods of time can have side effects, they are not for everybody. A newer type of NSAID, called a COX-2 inhibitor, has proven useful without the side effects associated with older NSAIDs, but they are more expensive and carry their own set of risks. Fortunately, other medications are available as well.

Treatment Options for the More Severe Forms of the Disease
Disease-modifying antirheumatic drugs (DMARDs) comprise several classes of medications that work by altering the way the immune system functions in an attempt to stop the underlying processes that cause the joint and tissue damage associated with psoriatic arthritis. They are often indicated as the second line of treatment for patients who are unresponsive to NSAID therapy or who have a more destructive form of the disease.

One particular class of DMARDs, known as steroids, includes such drugs as prednisone. Steroids have proven beneficial when it comes to reducing inflammation, swelling and acute, severe joint pain. They are commonly used by nondermatologists to treat psoriatic arthritis. Sometimes doctors recommend injections of a steroid when a single joint is severely inflamed. At times, steroids can also improve range of motion; however, there are problems associated with their use. Like NSAIDs, they have significant side effects when taken long term, and it is possible for psoriasis to intensify when the drug is stopped.

Other DMARDs that are effective in treating psoriatic arthritis include antimalaria medications such as Plaquenil® (hydroxychloroquine). It is simple to use and has few side effects, but it too can cause psoriasis to intensify. An organ rejection drug, such as cyclosporine, works quickly to halt the overactive immune system and has proven helpful to patients with severe psoriatic arthritis who have not responded to other systemic therapies. However, it impacts the immune system's ability to fight infection, and its benefits stop once the drug is discontinued.

Methotrexate is a chemotherapy agent that has been utilized for more than 40 years. It stops the out-of-control cells sparked by the malfunctioning immune system, but patients must be closely monitored because of its serious side effects.

Biologic agents are a relatively new class of DMARDs. Well-tolerated, they are genetically engineered to target the specific proteins in the immune system that are causing inflammation and pain. Biologics are well tolerated but very expensive. However, they also carry risks for some patients, including an increased risk of infection, and remain prohibitively expensive.

In addition to medication, several other therapies are recommended. They are:

• Exercise. Daily movement can limit the pain and swelling that make joints stiff. Exercise can also strengthen muscles, stabilize the joints, improve sleep, strengthen the heart, increase stamina and reduce weight. However, no exercise program should be started without the supervision of a physician. Very often, a physical therapist may be able to recommend specialized isometric exercises, as well as a stretching routine. Also, regular aerobic exercise has proven useful in improving patients' quality of life.
• Rest. Rest and adequate sleep should decrease the fatigue and joint inflammation associated with the disease. When psoriatic arthritis causes extreme fatigue, even more rest may be required.
• Hot and cold treatments. Each provides temporary pain relief and can reduce joint swelling, while improving range of motion. Doctors may recommend soaking in a warm tub or placing a warm compress or cold pack on a painful joint.
• Splints. A removable brace can immobilize inflamed joints, which may help reduce joint pain, swelling and stiffness. It's also useful if you have joint inflammation or problems with joint alignment or stability.
• Orthopedic shoes. When the digits in the toes are affected and swollen, or when enthesitis causes pain in the heel and makes walking painful, certain orthopedic shoes can provide relief. Shoe inserts, pads and heel cups may also be necessary.

Surgery is Usually the Last Resort
Most people with psoriatic arthritis never need surgery. However, there are times when severely damaged joints require arthroplasty, which is better known as joint replacement surgery. During this procedure, natural joints are replaced with prosthetic ones in an attempt to restore function and range of motion. Also, surgery may be indicated to relieve pain, improve movement and/or improve the physical appearance of the affected area.

Physicians Know Best
Without treatment, psoriatic arthritis has the potential to be disabling and crippling. Fortunately, that does not have to happen, illustrating the importance for patients to work with healthcare professionals, who can recommend the most appropriate treatment for each individual.