Psoriatic arthritis (PsA) is a type of inflammatory arthritis that causes swelling and pain in the joints and tendons. It is a chronic disease, meaning it requires long-term management to control symptoms and prevent joint damage. There is no one standard treatment plan for psoriatic arthritis because PsA affects everyone differently. You and your rheumatologist, dermatologist, or other health care providers may need to try different drugs or drug combinations to find the right treatment. You may also need to change medications throughout your life.
To better understand when it might be time to ask your rheumatologist about trying something new, MyPsoriasisTeam spoke with Dr. Arthur Mandelin, a rheumatologist at Northwestern Memorial Hospital in Chicago and an associate professor of medicine at Feinberg School of Medicine at Northwestern University. Dr. Mandelin shared four signs it might be time to switch PsA treatments.
Medications commonly used to treat PsA include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologic drugs, and corticosteroids (steroids). The right treatment option for you depends on several factors, including what areas of the body are affected and what symptoms are most bothersome to you.
“The main thing that patients and doctors need to think about when starting treatment for psoriatic arthritis would be the patient’s goals of therapy,” Dr. Mandelin said. “The [symptom] that bothers the patient the most, that might guide us into choosing certain drugs over other drugs.”
Once you and your doctor decide which path to try first, you may hope to find immediate relief. However, some medications can take weeks or months to start working.
“Generally speaking, in most of rheumatology, the suggestion has always been to give a drug three months unless you absolutely, positively cannot tolerate it and are miserable,” Dr. Mandelin explained. “For any drug that you take, you need somewhere around five or six doses before your body is at a stable level of that medication. If a drug is only being taken every other week, as some are, five or six doses can be quite a period of time that you have to wait.”
Ask your doctor for an estimated timeline. Although each person’s experience is unique, knowing approximately when you should expect to feel relief can help you understand whether the treatment really isn’t working for you or if you just need to give it more time.
“Some patients need to take several doses before they feel anything, and then they get a fairly rapid escalation,” Dr. Mandelin explained. “They go from ‘I don’t feel I’m being helped’ to ‘This is starting to work. This is really working. I’m very happy.’ It varies from patient to patient.”
When you are starting a new medication, open communication with your doctor is particularly important. Talk to your doctor about improvements, or lack of improvement in your symptoms and any challenges you may be having with your new treatment.
Some medications used to treat PsA can cause side effects, from nausea and headaches to heart problems and liver damage. Before starting any new treatment, ask your doctor what side effects to expect and whether they are generally mild, moderate, or severe, as well as if there is a chance your body will adjust over time.
“Certain side effects do tend to mellow as you’re on the drug longer, while others do not,” Dr. Mandelin explained.
Discussing potential side effects with your rheumatologist ahead of time can make it easier to cope with them if they occur. Ask about potential scenarios. If you have a headache, can you take an over-the-counter pain reliever? If so, which one? If you have stomach pain, should you go to the emergency room? How long will you need to take the drug before deciding if the side effects are worth the benefits?
Reach out to your doctor about side effects if you have concerns. “I would be happy to have patients contact me at week one, week two if they’re having a side effect to discuss with me what’s the side effect — specifically, how intense it is — and is it reasonable to think that this might be something that would mellow with time,” Dr. Mandelin said.
If someone is experiencing a side effect that is intolerable or will not dissipate over time, it might be appropriate to switch treatments, Dr. Mandelin noted.
Some PsA medications can become less effective over time. If you ever feel like you aren’t getting the same level of relief as before, you are likely not imagining it, and you are definitely not alone.
“A clue that can be very important sometimes is if it still seems that the drug works, but it doesn’t last anymore,” Dr. Mandelin described. For a drug that is administered every two weeks, “you’re fine for the first week, but then for the second week, you’re wishing that you could take it already.”
“The patient for whom the drug initially did work and now doesn’t has probably developed antidrug antibodies,” Dr. Mandelin said. “Many of these drugs are proteins, and our immune system is really good at identifying foreign proteins. The body obviously doesn’t know that this [protein] is being put there intentionally and with a therapeutic purpose. It only knows that it’s a foreign protein. Now, as fast as you can pour the drug in, the body is inactivating it and tearing it apart, recognizing it appropriately as, but unfortunately as, a foreign protein and destroying it.”
Biologics are one type of drug used to treat PsA that can become less effective over time because the body develops antibodies to the drug. In one study, researchers looked at data to explore why people with PsA and psoriasis vulgaris might switch biologics or stop taking them altogether. They found that in 26.4 percent of cases, the biologic didn’t provide symptom relief. In 36.5 percent of cases, the drug initially provided relief but lost its efficacy over time. Other reasons for stopping the drug included a change in health care providers, side effects, comorbidities, and cost.
This doesn’t mean biologics aren’t worth taking. They can be very effective for people with severe PsA. But it can be helpful to know that you may need to switch to a different drug or dose at some point. Dr. Mandelin said, “I’ve had a few patients who had a drug work for a decade or more before it finally seemed to fade over time.”
If you used to get relief from your PsA medication but it is becoming less effective, it might be time to talk to your doctor about other medication options. These might include other biologic drugs or a different class of drugs. There are many different classes of medications such as Janus kinase (JAK) inhibitors, tumor necrosis factor (TNF) inhibitors, and interleukin inhibitors.
If you have a new symptom, like joint pain in a different part of the body, or if your existing symptoms seem to be getting worse, you might need to try a new PsA treatment.
People living with PsA may experience flare-ups. This is when symptoms of psoriatic arthritis are more painful or intense than usual for a day, a week, or longer. Depending on the intensity and duration of a flare, your doctor may prescribe a new drug or increase your current dosage to help you through.
Your PsA treatment plan may need to evolve to address whichever symptoms are most affecting your quality of life. In some cases, your health care provider may recommend lifestyle changes that can help manage PsA, like doing light aerobic exercise, eating well, eliminating certain “inflammatory foods,” and losing weight. In others, they may recommend adjusting your medications.
If you are experiencing new or worsening PsA symptoms, it might be time to talk to your doctor about other options.
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