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Symptomatic treatments
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NSAIDs
In PsA patients with peripheral arthritis, NSAID monotherapy without DMARDs should not exceed 1 mo if disease activity persists.
10
In the case of axial or entheseal involvement, NSAID therapy may be continued for up to 12 wks if relief has already been achieved after 4 wks.
10
Because of the potential for side effects (eg gastrointestinal complications, hepatic complications, allergic complications, cardiovascular complications and chronic kidney disease), NSAIDs should be used with caution. NSAIDs such as celecoxib are contraindicated in patients with hypersensitivity to celecoxib, patients with history of asthma, urticaria, or other allergic type of reactions after taking NSAIDs. NSAID use should be avoided during the perioperative period in the setting of coronary artery bypass surgery.
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GCCs
Systemic GCCs: may be associated with skin flares. Should be used with caution, especially when treatment is being tapered for the potential worsening of skin symptoms. Intra‐articular injection of GCCs may rarely result in depigmentation.
124
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csDMARDs
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Methotrexate
Should be prescribed at an optimal dose of 25 mg per wk and with folate supplementation; if improvement does not exceed 50% of a composite measure for PsA within 3 mo or the treatment target is not reached within 6 mo, JAKi or bDMARD can be added to MTX treatment. Common adverse effects: gastrointestinal manifestations, hepatotoxicity, dizziness, photosensitivity. Should be used with caution in patients with impaired renal function, ascites pleural effusion and avoided in pregnant women due to its teratogenic effects. Other contraindications: liver disease, immunodeficiency syndrome, pre‐existing blood dyscrasias and in patients with hypersensitivity to MTX.
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Leflunomide
Effective and safe in the management of PsA, particularly in reducing tenderness, pain, fatigue, dactylitis, and skin disease in patients with PsA.
125
Common adverse effects: diarrhea, nausea, headache, rash, respiratory infection, abnormal liver enzymes. Should be used with caution in patients with severe infections. Caution should be taken for its use in pregnant women and in patients with severe hepatic impairment.
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Sulfasalazine
Shows greater improvement in patients with symmetrical polyarticular peripheral arthritis. Shows significant improvement in joint scores and reduction in disease activity as early as the 4th wk of treatment.
126
Well tolerated and safe in patients with PsA at a dose of 2.0 g/d. Patients with PsA who are known or suspected to have COVID‐19, should continue using sulfasalazine.
127
,
128
Common adverse events: gastric upset, skin rashes, headache, and liver disorders. Should be used with caution in patients with severe allergy, bronchial asthma, and glucose‐6‐phosphate dehydrogenase deficiency (G6PD). Should be avoided in patients with intestinal or urinary obstruction, porphyria, and hypersensitivity to sulfasalazine.
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tsDMARDs
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Apremilast
Effective in the treatment of biologic‐naïve patients with PsA and has a tolerable safety profile. Most common adverse effects: diarrhea and nausea. Should be used with caution in PsA patients with depression. Does not require routine therapeutic monitoring. Safe and effective therapeutic option in the HIV‐infected population with psoriatic arthritis.
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Tofacitinib
Safe and effective in the management of csDMARD‐IR/ TNFi‐naïve and TNFi‐IR patients and is effective in PsA patients with enthesitis and dactylitis. Patients with recurrent deep‐vein thrombosis and those at high risk of shingles infection should exercise caution. Has an acceptable safety profile with a low incidence of serious infections, malignancies, cardiovascular events, and gastrointestinal complications.
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Upadacitinib
Safe and effective in the management of patients with active PsA. Common adverse effects: upper respiratory tract infections, nausea, cough, and pyrexia. Patients with active and serious infections, malignancy, thrombosis, and gastrointestinal perforation should be treated with caution.
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