The importance of early intervention

PsA causes inflammation (swelling, pain and warmth) in the affected joints.

PsA can cause permanent joint damage quickly when it is not treated and controlled. This damage can even occur when the pain is not severe. Once damage occurs, it is not reversible and can cause significant pain and disability. Research has confirmed that treating PsA early and aggressively often improves the long-term outcome and significantly reduces damage. Early intervention and timely treatment therefore is critical to control the condition.

Once your diagnosis is confirmed, there are many treatments that can help decrease your pain and increase your movement. Non-medication therapies such as physiotherapy, occupational therapy, education, physical activity and relaxation techniques can all be helpful in the treatment of PsA.

Drugs

The process of inflammation is similar in the skin and joints, so treatment aimed at one aspect of the condition often helps the other as well. The general approach to treating PsA is to reduce joint inflammation and prevent long-term damage to the joints.

The cornerstone of therapy is Disease Modifying Anti-Rheumatic Drugs (DMARDS). They are often used in combination with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and /or Corticosteroids (steroids). Although NSAIDs and steroids slow down the day-to-day inflammation, they don’t affect the long-term outcome of the disease.

A newer class of medication called biologics has revolutionised the treatment of PsA. These medications, which can be used in combination with DMARDs, also suppress inflammation and help prevent damage to the joint.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying drugs (DMARDs) tackle the causes of inflammation (pain swelling and stiffness) in the joints. DMARDs are important because they help prevent damage to the joint.

Your doctor will recommend a therapy that is best suited to your type and stage of arthritis, other medical problems and medications. Sometimes these drugs are given by injection.

Taking any medication carries some risk, which must be balanced against the potential benefits. It is important to recognise that the risk of joint damage and permanent disability is much greater than the risk of side effects from DMARDs to control the disease. When properly monitored, the vast majority of side effects are rare, and most are reversible by adjusting the dose or switching medications.

Phosphodiesterase 4 inhibitors

This newer therapy offers a treatment option for people who cannot use DMARDs or when one of these type of medicines did not work.  It works by reducing the activity of an enzyme in the body called ‘phosphodiesterase 4’ which is involved in the process of inflammation. Apremilast (Otezla®) is one such medication.

Biologic Therapies

Biologic therapies are a newer group of disease-modifying drugs that may be used if other DMARDs aren’t working well enough. These are given either by injection or through a drip into a vein.

This also includes a category of medicines called biosimilars. These drugs are follow-on versions of original biological medicines. They are independently developed after the patent protecting the original product has expired. Biosimilar medicines are intended to have the same mechanism of action as the original biological medicines and are designed to treat the same diseases as the innovator’s product. Two biosimilars are currently available in Ireland for PsA - Inflectra™ and Remsima™.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications used to treat the pain and inflammation of arthritis. They act by blocking the inflammation that occurs in the lining of your joints. They can be very effective in controlling pain and stiffness.

Steroid Injections

Steroid tablets aren't generally used for psoriatic arthritis. However, your doctor might recommend steroid injections if your joints are particularly painful or your ligaments and tendons have become inflamed.

Skin Treatments

Your skin will usually be treated with ointments. There are five main types;

1. Tar-based ointments

2. Dithranol-based ointments (it's very important not to let these come into contact with normal skin)

3. Steroid-based creams and lotions

4. Vitamin D-like ointments such as calcipotriol and tacalcitol 

5. Vitamin A-like (retinoid) gels such as tazarotene

Properly caring for your skin will help you manage your symptoms. If you have severe psoriasis you should see a dermatologist.

Other treatments

If the creams and ointments don't help your psoriasis, your doctor may suggest the following;

a. Light therapy - short spells of exposure to high-intensity ultraviolet light

b. Retinoid tablets

Note that many of the DMARDs used for psoriatic arthritis will also help your skin condition. Similarly, some of the treatments for your skin may help your arthritis.

Treatments for nail psoriasis are usually less effective than the skin treatments. Many people use nail varnish to make the marks less noticeable.

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