NSAIDs, DMARDs, and biologics: what role do they play in treating psoriatic arthritis? If you're not familiar with these acronyms, I explain them briefly here. I'm going to turn to a great article in the International Journal of Advances in Rheumatology to help me explain the use of these drugs for psoriatic arthritis.
NSAIDs
NSAIDs have been the mainstay of treatment for psoriatic arthritis for decades. NSAIDs are not used to treat skin psoriasis, but taken at anti-inflammatory doses, their symptomatic relief for peripheral arthritis, spondylitis, enthesitis, and dactylitis (components of psoriatic arthritis) make these drugs an important part of many patients' PsA treatment.[1] NSAIDs' effectiveness is typically modest, but that is sufficient for some patients, and they can also be used in combination with DMARDs and TNF inhibitors. NSAIDs are primarily taken in pill form. Ibuprofen and naproxen, also known as Advil and Aleve, are two popular over-the-counter options, but there are dozens of prescription varieties. A few topical prescription NSAID options also exist.In years past, there was concern that NSAIDs might worsen skin psoriasis, but thankfully studies have not supported that idea.[1] Some of the major risks for long term NSAID use are in the gastrointestinal realm. It's important to keep regular labs while on NSAID therapy, and to consult your doctor if you experience GI distress.
DMARDs
If NSAIDs are not sufficient, DMARDs are typically the next step. Sometimes this step is skipped if your disease presentation is primarily axial because DMARDs don't seem to work for axial arthritis as well as for peripheral arthritis.[1] DMARDs sometimes used in the treatment of PsA include methotrexate, sulfasalazine, leflunomide (Arava), hydroxychloroquine (Plaquenil), azathioprine (Imuran) and cyclosporine.[2] These drugs are unrelated in all but name, so it's difficult to generalize how they work. Methotrexate and sulfasalazine are the two DMARDs most commonly prescribed for PsA.[1]Methotrexate blocks several enzymes that play a role in the immune system.[3] It is not fully understood how methotrexate decreases the severity of arthritis, but... it just does, for many people. Also used to treat cancer, methotrexate is used in much lower doses for PsA and psoriasis. Many of the worst side effects listed in its prescribing information are mainly a concern at the higher doses intended for cancer, but there are still some side effects to be aware of. Nausea, vomiting, and abnormalities on liver function tests are the most common side effects.[3] Methotrexate should be discontinued for at least 3 months before attempting to become pregnant - it can cause serious birth defects and pregnancy complications.[3]
Sulfasalazine is a combination of an aspirin-like anti-inflammatory medicine with a sulfa antibiotic. This combination arose at a time when rheumatoid arthritis (the condition it was originally developed for) was believed to be caused by a bacterial infection.[4] We now know that isn't true, but sulfasalazine works for many RA and PsA patients anyway, for reasons that aren't fully understood. Sulfasalazine is taken orally. Most patients have few side effects to sulfasalazine, but the most common ones are nausea and abdominal discomfort.[4]
Biologics
The third tier of PsA treatment: TNF inhibitors and other biologic drugs. You've undoubtedly seen TV ads for these high dollar medications, some featuring celebrities who truly have PsA (golfer Phil Mickelson) or psoriasis (model CariDee English), and others with actors pretending to have one of a variety of autoimmune diseases that these drugs treat.There are currently 4 biologics approved for the treatment of PsA: etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade) and golimumab (Simponi).[5] All 4 of these drugs are TNF inhibitors, which work by suppressing a very specific portion of the immune system, TNF-alpha, which is involved in triggering inflammation.[5] Enbrel, Humira, and Simponi are delivered via self-injection under the skin. Remicade is given via infusion in a doctor's office or infusion center. There are a number of other biologics currently under study for the use in PsA including certolizumab pegol (Cimzia), alefacept (Amevive), apremilast, and ustekinumab (Stelara).[6] We may see these drugs added to our treatment options before too much time goes by!
There are some very serious potential side effects to these drugs, the most common being an increased incidence of serious infections (less common risks include not-so-fun things like lymphoma, drug-induced lupus, new or worsening psoriasis, brain demyelination, and heart failure), but the positive results they can have are dramatic![7] It's a difficult choice that each of us must make as we weigh our treatment options. I've personally decided that biologic drugs are worth the risk, but I completely understand when other patients decide against biologics for themselves.
I have personally tried 8 NSAIDs, 2 DMARDs, and 3 TNF Inhibitors with varying degrees of success and failure. I currently take 1 NSAID, 1 DMARD, and 1 TNF Inhibitor as the core of my PsA treatment. I welcome any private questions about my personal experiences with these medications. Email me at copingwithpsa [at] gmail [dot] com.
References
[1] Ceponis, A., & Kavanaugh, A. (2011, June). Psoriatic arthritis: advances in therapy. International Journal of Advances in Rheumatology, 9(2), 45-55.
[2] Emery, P. & Ash, Z. (2012, September). Psoriatic arthritis. Retrieved from http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/psoriaticarthritis.asp
[3] Cannon, M. (2012, May). Methotrexate. Retrieved from http://www.rheumatology.org/practice/clinical/patients/medications/methotrexate.asp
[4] Cannon, M. (2012, May). Sulfasalazine. Retrieved from http://www.rheumatology.org/practice/clinical/patients/medications/sulfasalazine.asp
[5] National Psoriasis Foundation. (n.d.). Treating psoriatic arthritis with biologic drugs. Retrieved from http://www.psoriasis.org/psoriatic-arthritis/treatments/biologics
[6] Bernstein, S. (2011). Cutting edge of treatments in psoriatic arthritis. Retrieved from http://www.arthritistoday.org/conditions/psoriatic-arthritis/psoriatic-arthritis-treatment-research.php
[7] Abbott Laboratories. (2012, September). Prescribing information. Retrieved from http://www.rxabbott.com/pdf/humira.pdf
