Psoriatic Arthritis: Management

Who is involved in treating psoriatic arthritis?
After receiving a diagnosis of psoriatic arthritis the next step is to decide what sort of management or 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 (specialist in diseases of joints, muscles and bones) and may include:

• a dermatologist
• a physiotherapist
• a specialist nurse
• an occupational therapist
• a podiatrist
• a psychologist/counsellor
• other allied healthcare professionals (HCP)
• an opthalmologist.

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 (comes and goes) with episodes of flare (active psoriatic arthritis), which will then settle of their own accord (remission).

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

Your healthcare professional will assess your prognosis (how your psoriatic 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.

Shared decision-making

Deciding which treatment is right for someone with psoriatic arthritis is not just a healthcare providers decision based on which treatment is best. It is a collaborative process that should involve a person and their healthcare professional working together to reach a joint decision about care. It could be care that you need straight away, or care in the future, for example through advanced care planning. It involves choosing tests, treatments based on both evidence and on the persons individual preferences, beliefs and values. It means making sure you understand the risks, benefits and possible consequences of different options through discussion and information sharing. This will be different for each person with psoriatic arthritis.

People with psoriatic arthritis should be prepared to ask questions of their team during consultations. You may wish to write the questions down in advance to remind you.  You should, equally be prepared to take decisions as to whether you will or will not accept treatment for your condition.  Discussions may also include issues relating to fertility and starting a family.

Assessment

The first steps in deciding how to manage psoriatic arthritis will be taken when your healthcare professional has assessed your condition. The assessment may include other members of a team, who will examine your joints to see how they are affected; you may also have imaging (x-rays or other types of scans) and blood tests as part of this assessment. With this information your team will be able to develop a plan to manage your condition.

Damage to your joints, visible on diagnostic imagery, or high inflammation markers on your blood tests, can indicate a greater likelihood of damage in the future. If this is the case 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.

Best practice

There are various management considerations that will be taken into account. These are based on careful consideration of risks and benefits including scientific evidence from research studies. Your healthcare provider may follow existing recommendations as produced by professional groups such as the British Society for Rheumatology or those produced by NHS advisory groups such as the National Institute for Health and Care Excellence (NICE) or the Scottish Medicines Consortium (SMC). There may also be local health board guidance around access to certain therapeutic interventions depending on where you live within the UK.

Available therapies

These may include drug and non-drug therapies. Drug therapies are generally ranked by potential side effects (a non-intentional effect that can occur from a medication 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 adverse reactions (AVR). Many people will also be offered other forms of therapeutic interventions.

Medical therapy:

 analgesics (painkillers such as paracetamol)

• non-steroidal anti-inflammatory drugs (NsAIDS)
• steroids
• disease modifying anti-rheumatic drugs (DMARDS)
• biologic drugs
• non-biologic drugs

Surgical therapy:

 soft tissue removal (synovectomy)

• joint replacement (arthroplasty)
• joint fusion (arthrodesis)
• joint realignment (osteotomy)
• removal of dead or damaged bone tissue (debridement)

Non-drug therapy:

•  physiotherapy (restore movement and function)
• occupational therapy (rehabilitation and adaptation)
• psychological therapy (talking therapies)
• podiatry/chiropody (foot, ankle and lower limb)
• orthotics (devices)
• holistic therapy (whole person complementary therapies)

Treatment considerations

Given the wide-ranging options that are available for people affected by psoriatic arthritis, careful consideration will be given to finding the appropriate pathway towards improving your condition.

The main goals when considering treatment are to:

• prevent flare ups
• ease pain
• reduce stiffness
• alleviate fatigue
• avoid joint damage

Treatments such as physiotherapy, exercise and education about psoriatic arthritis are likely to benefit almost everybody with the condition. 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 inflammatory diseases are no exception. Even a milder drug that is available without prescription, 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.

Alongside these therapies many people with psoriatic arthritis will benefit from disease modifying drugs. These drugs either act to suppress the over response of the immune system or by targeting and suppressing parts of the immune system, that are known to be causing the inflammatory process.

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.

For further information on treatments see our Treatments for Psoriasis: An overview  and  Treatments for Psoriatic Arthritis: An overview. For information about physiotherapy and exercise see Keeping active.

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, scans 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.

Patient initiated follow-up (PIFU)

NHS England is supporting healthcare providers to roll out patient-initiated follow-up (PIFU). This is to give patients and their carers the flexibility to arrange their follow-up appointments as and when they need them. Deciding when you need to see your healthcare provider again should not necessarily be dictated by a set period of time. In the past PIFU may have gone under the terms open access follow-up, patient led follow-up, patient triggered follow-up or self-managed follow-up. Essentially these are designed to empower you to manage your own condition and play a key role in the shared decision-making process.

Conclusion

Being diagnosed with psoriatic arthritis can be a very distressing and confusing time. But with good management you will be able to understand what is happening to you and how best to cope with the effects of living with an inflammatory arthritis. Being an active part of the decision-making process about your health, will not only empower you, but will also help you lead the best life you can in spite of the effects that psoriatic arthritis may have on you.

This article is adapted from the Psoriatic Arthritis: Management leaflet. 

Download our Psoriatic Arthritis: Management leaflet as a PDF