HHE 2018 | Page 179

Choosing the appropriate treatment in each patient The current treatment armamentarium for PsA encompasses different drug classes , including non-steroidal anti-inflammatory ( NSAIDs ), conventional disease modifying anti-rheumatic rugs ( cDMARDs ) and biologics ( bDMARDs ), as well as small molecules . However , despite the increasing availability of therapeutic strategies , we rely on PsA clinical features to choose the most appropriate treatment , 25 there are few objective measurements , that is , CRP , to measure its efficacy . 8 For patients with mild oligoarticular presentation , NSAIDs and intra-articular injections can be effective , but in patients with more severe symptoms , cDMARDs are typically prescribed as the initial treatment . Unfortunately , there are limited data from randomised clinical trials for cDMARDs in PsA , and their efficacy is mostly suggested by rheumatoid arthritis studies . A small real-life study suggested that methotrexate ( MTX ), sulfasalazine ( SSZ ), and leflunomide are effective in reducing peripheral arthritis and enthesitis , while SSZ use is associated with the greatest improvements . 26 Moreover , a randomised clinical trial on MTX did not show a significant treatment effect , but that could have been a result of the low doses prescribed , 27 as in real-life it is the most frequently used cDMARD . 28
The treatment of PsA is complicated by the heterogeneous clinical manifestations , on which cDMARDs are poorly effective , while bDMARDs suppress both skin and joint disease , retard radiographic progression , and are effective for enthesitis , dactylitis and axial involvement .
Psoriatic arthritis represents the ideal field to apply a holistic approach based on multiple specialists , centred around the rheumatologist and dermatologist
Therefore , up to 40 % of PsA patients are treated with bDMARDs in real-life , with etanercept , directed towards tumour necrosis alpha ( TNFa ) being the most frequently prescribed according to a large epidemiological study . 28 Beyond TNFa inhibitors , bDMARDs with other mechanisms of action ( targeting interleukin ( IL ) -17 and IL-12 / 23 ) are effective and safe in PsA . Moreover , in the past , small molecules , or medications inhibiting intracellular signalling pathways ( Janus kinase or phosphodiesterase 4 ) have supplemented the therapeutic armamentarium for PsA .
In addition to pharmacotherapy , patient education and physical activity are crucial in the management of PsA , in particular , lifestyle modifications including smoking cessation , weight reduction and stress management .
Finally , recommendation on the treat-to-target strategy for PsA have been made , since it has been demonstrated that a target-driven approach in rheumatoid arthritis is superior to usual care for clinical , functional and structural outcomes . According to the most recent recommendations , remission / inactive disease of musculoskeletal and extra-articular manifestations should be the treatment target ; however low / minimal disease activity might be an alternative target . It is important therefore to measure disease activity based on clinical signs and symptoms , as well as acute phase reactants . We have numerous tools to measure disease activity , of which some have been specifically developed and validated for PsA . In particular , for PsA , DAPSA ( disease activity index for psoriatic arthritis ) and MDA ( minimal disease activity ) should be considered to define the target . 29
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