If you are living with psoriatic arthritis (PsA), you may need to change medication types or dosages over the course of your treatment. Common reasons for switching PsA treatments include not getting enough relief, experiencing intolerable side effects, finding that a medication has become less effective, and developing new or worsening symptoms.
In this article, we provide six questions to ask your rheumatologist, dermatologist, or other health care providers about your PsA treatment plan. First, here are a few key points to remember:
To help you prepare for a conversation about psoriatic arthritis treatments, MyPsoriasisTeam spoke with Dr. Arthur Mandelin, a rheumatologist at Northwestern Memorial Hospital in Chicago and an associate professor of medicine at Northwestern University Feinberg School of Medicine. You can use this list at your next appointment. Or, use it as a starting point to create your own.
Common treatment goals for PsA include:
“We consider psoriatic arthritis to have a number of different domains,” Dr. Mandelin said. “It depends which domain is the most dominant one, the one that bothers the patient the most might guide us into choosing certain drugs over other drugs.”
What are your treatment goals? You can ask your doctor to help you think through this before deciding on a new PsA treatment. If you have children or grandchildren, combating fatigue may be important so you can enjoy family activities. If you play golf or cycle, protecting your range of motion may be essential to your quality of life. If pain is affecting your sleep and daily life, effective pain management is likely on your list of priorities. Like your symptoms, your treatment goals may change over time.
Once you have outlined your goals, ask your doctor if and how a new medication will help you achieve them.
Some treatments for PsA can take a few weeks or months before they start to work. It may be helpful to know when you can expect to feel the full benefits of a medication.
“We don’t want the patient to wait one day longer than they have to,” Dr. Mandelin said. “But we also don’t want them to throw in the towel at week two if waiting four to six more weeks might have been the difference between something that doesn’t appear to be working and something that turns out to be something the patient actually likes quite a bit.”
Dr. Mandelin explained that a general guideline in rheumatology is to give a new medication three months before deciding if it works for you. The exception to this is if you’re experiencing intolerable side effects.
Ask your doctor when most people feel the full benefits of a treatment. You can ask your doctor if there are other medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), that can help bridge the gap while you wait.
Every medication carries the risk of side effects. Ask your doctor about the side effects of a potential PsA medication and what you can reasonably expect. When your doctor explains the potential side effects of a new PsA medication, ask about side effects that tend to persist and those that tend to go away with time. Dr. Mandelin explained that some side effects of treatments are short term, while others are likely to persist.
Whatever side effects you’re experiencing, you can reach out to your doctor with questions and concerns. “I would be happy to have patients contact me at week one or week two if they’re having a side effect,” Dr. Mandelin commented. “We can discuss the side effect, how intense it is, and if it is reasonable to think that this might be something that would mellow with time.”
In cases when side effects are intolerable and unlikely to ease up, Dr. Mandelin explained that switching treatments early might be necessary. If you’re experiencing intolerable side effects, the next step could be trying a different medication in the same category or a new type altogether.
Dr. Mandelin explained that the biologic drugs used to treat PsA are human-made proteins, and the body is very good at identifying foreign proteins. “Anytime you put a nonhuman protein into a human, there’s a chance that the body will get smart and recognize that that drug is not a human protein, it’s a man-made protein,” Dr. Mandelin said. “The body obviously doesn’t know that this is being put there with a therapeutic purpose.”
Because your immune system doesn’t know that your PsA treatment is trying to help you, it may create antibodies in an attempt to protect you. Over time, these antibodies can make your medication less effective.
“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. “The blood level of the drug is falling and getting to zero sooner than it should.”
Talk to your doctor if you feel like your biologic drug is becoming less effective. Oftentimes, your doctor will consider switching to a different biologic, Dr. Mandelin explained. Other options may include adding a disease-modifying antirheumatic drug (DMARD) to your treatment plan or trying a medication in a new category, such as a Janus kinase (JAK) inhibitor.
People with psoriatic arthritis or psoriasis may be more likely to have certain other health conditions, including heart disease, lung disease, or inflammatory bowel disease. Certain PsA medications may not be appropriate, depending on your other health concerns or other medications you’ve been prescribed.
“The doctor and the patient should be discussing, do you have diabetes, do you have cardiovascular risk factors? What other health problems do you have? What other medicines might you be on that might narrow the field or, or make us prefer one drug over another?” Dr. Mandelin explained. Your doctor may also ask you questions about lifestyle factors like smoking or smoking history, he added.
Here are some factors that may influence the best treatment option for you:
Some insurance providers in the United States require people to go through a process called step therapy. This generally means starting with a less expensive drug and demonstrating that it’s not effective or that it causes very burdensome side effects before the insurance company will cover a more expensive one.
If your insurance company denies your preferred psoriatic arthritis treatment, you can appeal the decision. In some cases, your doctor may be able to help you get a short-term supply of the new medication from the drug manufacturer while you appeal. Talk to your doctor or visit the National Psoriasis Foundation’s free Patient Navigation Center for help.
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