Psoriatic arthritis: When to treat

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About psoriasis and psoriatic arthritis
Who is involved in treating psoriatic arthritis?
Planning to treat
Assessment
Treatment options
Treatment considerations
A partnership
Reviewing treatments

What are the aims of this leaflet?

This leaflet has been written to help you understand more about who is involved in the ongoing monitoring and treatment of your psoriatic arthritis, including options, decisions, planning and assessments.

About psoriasis and psoriatic arthritis

Psoriasis (sor-i’ah-sis) is a long-term (chronic) scaling disease of the skin, which affects 2%-3% of the UK population. It usually appears as red, raised, scaly patches known as plaques. Any part of the skin surface may be involved but the plaques most commonly appear on the elbows, knees and scalp. Living with psoriasis and psoriatic arthritis can be challenging, stressful and even distressing. This can have a negative psychological impact on an individual’s life. See Psychological Aspects of Psoriasis  for more information.

About 10% to 20% of people with psoriasis may develop an associated psoriatic arthritis, which causes pain and swelling in the joints and tendons, accompanied by stiffness particularly in the mornings.

The most commonly affected sites are the hands, feet, lower back, neck and knees, with movement in these areas becoming severely limited. For more detailed information on psoriasis and psoriatic arthritis see our  About Psoriasis and About Psoriatic Arthritis.

 
Who is involved in treating psoriatic arthritis?

After receiving a diagnosis of psoriatic arthritis the next step is to decide what sort of treatment would be best for you. This process will involve discussion with a team of healthcare professionals involved in your care. This team is usually, but not always, led by your doctor (GP) or a rheumatologist and may include:

  • a dermatologist
  • a physiotherapist
  • a specialist nurse
  • an occupational therapist
  • a podiatrist
  • a psychologist.

Planning your treatment should be a two-way process between you and your team to ensure you receive the treatment that is right for you.

Planning to treat

Psoriatic arthritis can be highly variable and different people may be affected in different ways, such as the number of joints or tendons affected. The best treatment for you may therefore be very different to the best treatment for someone else. Not only does the pattern of arthritis vary but it also waxes and wanes with episodes of flare (active arthritis) which will then settle of their own accord (remission).

Some people with mild disease may need minimal or even no treatment at all and people with severe disease may need stronger and even combinations of treatments. Drug treatments prevent damage to joints but cannot repair those already damaged, so the earlier treatment is received the better for people with severe arthritis.

Your specialist will assess your prognosis (how your arthritis may progress and how severely you will be affected) to identify if you may have a more severe form of psoriatic arthritis and so benefit from early treatment. This is not always obvious in the first year or two of the disease and since many individuals with psoriatic arthritis will only be mildly affected, simple and local treatment and the use of the safest drugs possible may be all that is recommended. If your arthritis does progress there are now a number of different drug treatments available.

Assessment

The first steps in deciding when to treat and which treatment is best for you will be taken when your specialists have assessed your condition. The members of your team will examine your joints to see how they are affected; you may also have x-rays and blood tests as part of this assessment. With this information your team will be able to make a prognosis. Damage to your joints visible on x-rays or high inflammation markers on your blood tests can indicate a greater likelihood of damage in the future and so you may benefit from more treatment. Psoriatic arthritis is very variable; a small number of people (5%) have a very severe form but the majority have milder patterns. There has been a lot of work carried out recently on the genetic predisposition of psoriatic arthritis, but doctors are not yet in a position to use genetic tests to make treatment decisions.

Treatment options

There are a wide range of treatment options available. These are generally ranked by potential side effects (a non-intentional effect that can occur from a treatment). Treatment is considered in a stepwise fashion. This allows people to climb this escalation of treatment in a way that means starting with the least intrusive therapy that might control their disease (and symptoms) with the minimum risk of unwanted side effects and may include:

 

Non-drug therapy:

  • physiotherapy (restore movement and function)
  • occupational therapy (rehabilitation and adaptation)
  • podiatry (foot, ankle and lower limb)
  • orthotics (devices)
  • complementary therapies (pilates, yoga, hydrotherapy etc).

Medical therapy:

  • analgesics (painkillers such as paracetamol)
  • non-steroidal anti-inflammatory drugs (NSAIDS)
  • steroids
  • disease modifying anti-rheumatic drugs (DMARDS)
  • biologic drugs.

Surgical therapy:

  • operations such as joint replacement (arthroplasty).

Treatment considerations

Treatment has two main goals: first to prevent flare ups and to improve your symptoms, such as reducing pain, stiffness and fatigue; and second to prevent damage to your joints. Treatments such as physiotherapy, exercise and education about psoriatic arthritis are likely to benefit almost everybody with the condition, though research in this area is very limited. Importantly, because these are not drug treatments they do not have the same potential for side effects.

Drugs used to treat any disease carry the possibility of side effects, some of them mild but some may be serious. The treatments used for rheumatic diseases are no exception. Even a milder drug that is available without prescript ion, such as aspirin or ibuprofen, can cause indigestion and/or gastrointestinal bleeding (such as stomach ulcers). The more powerful anti-inflammatory drugs, which are only available on prescription, also have a risk of side effects, particularly stomach ulcers.

Other drugs may have to be given alongside, to try to prevent these side effects. Your team will therefore try to find a balance in your therapy to give you the mildest treatment, with the fewest potential side effects, that will completely control your symptoms and disease.

The newer drugs, such as biologics, have and hopefully will continue to revolutionise the treatment of rheumatic diseases, including psoriatic arthritis, enabling many patients to lead a normal and relatively pain-free life. These more powerful drugs are not curative but may suppress the disease to a significant degree, for example preventing flares from occurring and preventing or delaying long-term damage to the joints. Their side effects have the potential of being more severe and can include damage to the bone marrow, kidneys, liver and skin. Biologic drugs therefore should only be prescribed after discussion between patient and doctor so that the risks, benefits and possible impacts are fully understood. For further information on treatments see  Treatments for Psoriasis and Treatments for Psoriatic Arthritis. For information about physiotherapy and exercise see  Physiotherapy & Exercise programme for psoriatic  arthritis 

A partnership

Deciding which treatment is right for someone with psoriatic arthritis is not just a specialist’s decision based on which treatment is best. Treatment needs to be tailored to each individual person and will be a balance of what therapy is most likely to improve the symptoms and disease and what each person’s thresholds are for taking medication and the risks of potential side effects. This will be different for each person with psoriatic arthritis, but the right decision will be possible through active discussion with the team looking after the individual.

People with psoriatic arthritis should be prepared to ask questions of their team during consultations and should equally be prepared to take decisions as to whether they will or will not accept treatment for their condition.

Reviewing treatments

Whatever treatment is decided on, it should be reviewed on a regular basis. How often you need to be reviewed depends on the treatment you have been given and should be discussed with your doctor. At your reviews your team will discuss your symptoms with you, examine your joints and may ask for blood tests or x-rays to reassess your condition. In this way the team can check the treatment is working and does not need to be changed.

This article is adapted from the Psoriatic Arthritis: When to Treat leaflet. 

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Always consult a doctor or your healthcare provider