The most common symptom of psoriatic arthritis is joint pain, but sometimes the first-line treatment, a nonsteroidal anti-inflammatory drug (NSAID), just isn’t enough to help it. The disease can become so severe that between 40 and 60 percent of people with psoriatic arthritis will develop joint damage.
“By the time patients get to me, it’s not just pain, it’s swelling,” says Waseem Mir, MD, a rheumatologist and affiliate of Lenox Hill Hospital in New York City. “When you’re dealing with joint swelling and the inability to bend a finger or ankle or knee, if you’re just taking an NSAID, that’s not going to help prevent joint damage.”
The next treatment recommended after NSAIDs is often methotrexate, which belongs to a class of the 1 last update 2020/05/27 drugs called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs include nonbiologic drugs — such as methotrexate — that have a broad affect on the immune system, as well as biologics.The next treatment recommended after NSAIDs is often methotrexate, which belongs to a class of drugs called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs include nonbiologic drugs — such as methotrexate — that have a broad affect on the immune system, as well as biologics.
“The decision to use a biologic agent in treating psoriatic arthritis is usually made after patients do not respond to an adequate trial of an NSAID drug, and sometimes a trial of methotrexate,” says Gary Margolies, MD, a rheumatologist at Saint Thomas Medical Partners in Nashville, Tennessee. In some rare cases, a patient may begin taking biologics right away, if their disease is particularly severe and their insurance company approves it.
Types of Biologics
Psoriatic arthritis is an autoimmune disease, which means the person's immune system is attacking its own body. Instead of treating pain and other symptoms, biologics target specific parts of the immune system to block activity from either T cells — killer immune cells — or particular proteins, including tumor necrosis factor-alpha (TNF-alpha), interleukin 17A (IL-17A), or interleukins 12 and 23.
Of the five biologics that target TNF-alpha, Humira (adalimumab), Enbrel (etanercept), and Remicade (infliximab) have been around the longest, while Cimzia (certolizumab pegol) and Simponi (golimumab) are newer.
The two other biologics used to treat psoriatic arthritis are Cosentyx (secukinumab), which targets interleukin 17A, and Stelara (ustekinumab), which targets interleukin 12 and interleukin 23. Ustekinumab is not typically prescribed until a person proves resistant to TNF-inhibitors, or hasn't been able to take them due to side effects or risks.
The TNF inhibitors all treat joint pain and skin symptoms with about equal effectiveness. Which medication a doctor prescribes depends on the individual’s condition, as well as patient preferences for how the medication is administered and how often.
Other considerations include the medication’s costs and the patient’s insurance coverage. “Generally, once a decision is made to initiate a biologic agent, the choice of agent is usually determined by which is preferred by the patient’s insurance provider,” Dr. Margolies says.
Before taking any biologics, your doctor should screen you for tuberculosis, human immunodeficiency virus (HIV), hepatitis A, hepatitis B, and local bacterial or fungal infections if appropriate. You cannot have an active infection when you start TNF inhibitors, and your doctor may suggest getting vaccinated against hepatitis B and tuberculosis.
Biologics are genetically engineered proteins derived from humans, animals, or microorganisms. Since these drugs are actually formulations of live antibodies, they must be injected subcutaneously or infused intravenously, like a vaccine. Most biologics for psoriatic arthritis can be self-injected, except infliximab, which requires IV infusion.
basal thumb arthritis stageshow to basal thumb arthritis stages for Some biologics will work within two weeks, but their full effect isn't typically seen for two to three months. If you don't respond after being prescribed a TNF inhibitor, your doctor will try a different one. After that, your doctor may try secukinumab or eventually ustekinumab.
Patients may take a biologic on its own or with methotrexate. A new drug, Taltz (ixekizumab), also targets IL-17A, and was approved in March 2016 for psoriasis. Recent clinical trials have suggested it effectively treats psoriatic arthritis as well, but patients should take it with methotrexate to reduce the chances of becoming resistant to ixekizumab.
Each biologic has a different schedule:
- Humira (adalimumab) is typically injected once every two weeks or weekly.
- Enbrel (etanercept) is injected once or twice a week.
- Remicade (infliximab) is delivered via three intravenous infusions at a doctor’s office during the first six weeks of treatment. After this, individuals receive one infusion every six to eight weeks.
- Simponi (golimumab) is a once-a-month injection.
- Cimzia (certolizumab pegol) is injected every two weeks for the first three doses and then every two or four weeks continuously.
- Cosentyx (secukinumab) is injected once a week for five weeks. After this, individuals receive an injection once every four weeks.
- Stelara (ustekinumab) is an injection first given in two doses, with one initial dose followed by another four weeks later. Then the schedule is once every 12 weeks.
- Taltz (ixekizumab) starts with two injections that are followed by an injection every two weeks for 12 more weeks. After that, injections are once a month.
What Are the Risks?
Some of the more common side effects with these biologics include upper respiratory infections, reactions at the injection site, and headaches. Depending on the biologic, you might also experience a rash or urinary tract infection, cold symptoms, diarrhea, abdominal pain, or fatigue.
“The risks of using these drugs are mainly thought to revolve around an increased risk of mild to serious infections, including tuberculosis and some fungal infections,” Margolies says.
Anyone taking biologics will undergo monitoring, which usually means an annual blood count and liver tests, but biologics aren’t appropriate for all patients. Individuals with active infections or a significantly compromised immune system should not take biologics. Patients with heart failure or multiple sclerosis (MS), or with a first-degree relative with MS, should not take the TNF inhibitors, but can take secukinumab or ustekinumab.
basal thumb arthritis stageshow to basal thumb arthritis stages for More serious but very rare side effects can also occur, including nervous system disorders, heart failure, blood disorders, or a syndrome similar to lupus. Infliximab and golimumab carry a very low risk of causing liver damage, and infliximab, golimumab, and ustekinumab have been linked to a small increased risk of cancer. A relapse of hepatitis B may occur with some biologics, too.
Talking to Your Doctor
basal thumb arthritis stageshow to basal thumb arthritis stages for These are the major questions you will want to discuss with your the 1 last update 2020/05/27 doctor:These are the major questions you will want to discuss with your doctor:
- Why do you think biologics will work for my psoriatic arthritis?
- Why do you want to try this specific biologic first?
- What are the side effects and more serious risks of this particular biologic?
- How long will it take before I start seeing the effects of the treatment?
- How will this drug be administered — subcutaneous injection or intravenous infusion?
- How often will I get this drug?
- Do I have any health issues that mean I shouldn’t take this medication, or that I have a higher risk of side effects?
- Can I breast-feed, become pregnant, or attempt to conceive while taking this medication?
- How much will this drug cost me?
- What are my next options if this drug doesn’t work?