Understanding oral medication options for psoriatic arthritis

Various oral treatments are available for psoriatic arthritis, including:

• nonsteroidal anti-inflammatory drugs (NSAIDs)
• apremilast (Otezla)
• conventional disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine, methotrexate, leflunomide, hydroxychloroquine
• targeted synthetic DMARDs known as Janus kinase (JAK) inhibitors, such as tofacitinib (Xeljanz) and upadacitinib (Rinvoq)

NSAIDs are anti-inflammatory medications that people can take for mild psoriatic arthritis to treat joint pain, stiffness, and swelling. They work quickly by blocking the enzymes cyclo-oxygenase 1 and 2. This leads to decreased production of prostaglandins, or hormone-like substances that bring on joint and spine pain and inflammation. However, they do not work to slow disease progression.

Otezla blocks the making of the enzyme phosphodiesterase 4. This helps decrease inflammation in the body, which can help improve psoriatic arthritis symptoms.

Conventional DMARDs work broadly throughout the body to slow disease progression and prevent irreversible, permanent joint damage that can otherwise occur with long-term joint inflammation.

To prevent inflammation, targeted synthetic DMARDs inhibit the JAK family of proteins, including JAK 1, 2, and 3 and tyrosine kinase 2. Cytokines are proteins in the body that signal cells to produce inflammation. JAK inhibitors interfere with this signaling process. Different JAK inhibitors block different inflammatory proteins.

In moderate to severe disease, if prescription NSAIDs are not enough to treat psoriatic arthritis, experts typically recommend conventional DMARDs. If DMARDs are ineffective, or if a person does not tolerate them well, a doctor can add a JAK inhibitor, or the person can take it alone as monotherapy. Another option in this circumstance is Otezla, which a doctor can prescribe on its own or with a conventional DMARD.

Yes, in fact, doctors often combine them to work as partners to increase each other’s effects.

Doctors can combine up to three conventional DMARDs with one another. A person can also take Otezla with a conventional DMARD. Doctors can also combine targeted synthetic DMARDs with conventional DMARDs.

A person should work with their doctor to determine the best medication, or combination of medications, to treat their psoriatic arthritis.

Conventional DMARDs, targeted synthetic DMARDs, and Otezla can slow down the inflammatory process and decrease the chances of permanent, irreversible joint damage, which can otherwise occur after inflammation over time.

NSAIDs can irritate the gastrointestinal tract, which may cause an ulcer or gastrointestinal bleeding. These drugs can also lead to heart problems, kidney damage, and in rare cases, liver damage.

Otezla may also irritate the gastrointestinal tract and lead to issues like abdominal pain, diarrhea, nausea, and vomiting. It may also cause headaches and symptoms like cough, runny nose, or fever.

Side effects of conventional methotrexate and sulfasalazine include bone marrow suppression. Methotrexate can cause liver damage and lung inflammation, leading to scarring or fibrosis.

Methotrexate is also an abortifacient, and pregnant people or people who plan to become pregnant must avoid it due to its harmful effects on a fetus. Those taking methotrexate should not drink alcohol since both can damage the liver.

Sulfasalazine can also reversibly lower the sperm count in men. It can also cause gastrointestinal symptoms such as nausea, vomiting, heartburn, headache, and rash.

Leflunomide can harm a fetus, and it can stick around in the body for 2 years. Should a person become pregnant while taking it, it requires a washout of the body within 2 years of taking it. It can also cause life threatening liver damage. People must avoid taking this medication if they have liver disease or consume alcohol heavily, have hepatitis, or take other medications that can cause liver damage.

Hydroxychloroquine can cause gastrointestinal side effects such as loss of appetite, nausea, vomiting, or abdominal pain. More importantly, it can worsen psoriasis, so while doctors can prescribe it to people with psoriatic arthritis, those people must avoid taking it if they also have psoriasis.

All JAK inhibitors have a cancer warning. Xeljanz may also increase the risk of blood clots in the lungs and major blood vessels, especially in those at risk, so people with risk factors for heart disease or those who have had a blood clot in the past should not take the medication.

A person should expect to start noticing some relief in 3–6 weeks. The complete effect of the treatment should be noticeable in 3 months.

If a person is unhappy with the results of their treatment regimen, they should talk with their doctor.

If a person misses a dose of their psoriatic arthritis treatment, they should take it as soon as they can. However, if it is already time for the next dose, they should not take a double dose to make up for the missed dose. A person should talk with their doctor if they miss doses of their medication regularly.

Yes, methotrexate, Otezla, and JAK inhibitors also work to help improve psoriasis skin involvement. However, hydroxychloroquine can worsen psoriasis.

Psoriatic arthritis is a chronic or lifelong disease requiring ongoing treatment. However, with the right treatment plan in place, remission is possible. If a person experiences remission, they can work with their doctor to adjust their treatment plan.

Dr. Stella Bard is an ABMS board certified rheumatologist with more than 10 years of hands-on experience in managing complex rheumatologic concerns. She is currently a practicing physician in the states of New York and Texas.