Since there currently isn’t a cure for psoriatic arthritis (PsA), the goal of treatment is to improve symptoms like joint pain and swelling. Ongoing treatment is essential to prevent permanent joint damage.
For moderate to severe PsA, treatment options usually include disease-modifying antirheumatic drugs (DMARDs) and biologics. These treatments may be used alone or in combination with each other.
Finding the right treatment for PsA can be difficult. Some treatments work well for a few months, and then stop working. Others may cause you to experience harsh side effects.
Here are some signs that it might be time to speak to your doctor about switching medications.
DMARDs, like methotrexate, are known to cause side effects such as:
- mouth sores
- upset stomach
- abnormal liver function
- reduced number of white blood cells
Biologics work in a more selective way than DMARDs. This means they often have fewer side effects than the less-targeted treatments. Biologics can still cause side effects, but they tend to be less common.
Common side effects of biologics include:
- redness and rash at the site of the injection
- increased risk of serious infections
- lupus-like symptoms, such as muscle and joint pain, fever, and hair loss
Rare side effects of biologics include serious neurologic disorders, such as multiple sclerosis, seizures, or inflammation of the nerves of the eyes.
If you’re taking a DMARD or immunosuppressant and your side effects are too severe, it may be time to ask your doctor about switching to a biologic.
Your doctor might also consider the possibility of combining your current DMARD therapy with a biologic. Combining treatments makes them more effective, while lowering the dose. This, in turn, helps to decrease side effects.
If you have a compromised immune system or active infection, you shouldn’t take biologics for your PsA.
There’s no one-size-fits-all treatment for PsA. You might find that a biologic seems to work for a little while, but suddenly your symptoms get worse again. Switching biologic therapies is recommended for patients who experience treatment failure.
Your doctor will consider many factors before deciding which agent to switch you to. This includes your treatment history, disease characteristics, comorbidities, and other risk factors. Your doctor will also consider your health insurance coverage and out-of-pocket costs.
There are nearly a dozen different biologics now approved to treat PsA, and many more in the pipeline.
Approved biologics include:
- tumor necrosis factor (TNF)-alpha inhibitors, such as certolizumab pegol (Cimzia), etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and golimumab (Simponi)
- interleukin (IL)-12/23 inhibitors, such as ustekinumab (Stelara)
- interleukin (IL)-17 inhibitors, such as secukinumab (Cosentyx), ixekizumab (Taltz), and brodalumab (Siliq)
- T-cell inhibitors, such as abatacept (Orencia)
- Janus-kinase (JAK) inhibitors, such as tofacitinib (Xeljanz)
If one treatment fails, your doctor will carefully consider which biologic to switch you to. This is based on current treatment guidelines and recommendations.
Research shows that adalimumab and etanercept may not work as well if you’ve already tried a TNF-inhibitor. Ustekinumab and secukinumab, on the other hand, show better efficacy in patients who fail to respond to a TNF-inhibitor.
This is also a good time for your doctor to consider combining treatments. Research shows that infliximab, etanercept, and adalimumab are more effective when given with methotrexate.
Keep in mind that it may take up to three months or more for a biologic to take full effect.
New symptoms or an increase in flares could be a sign that your current treatment regimen isn’t working for you.
Talk to your doctor about switching treatments if you start having any of these symptoms, or your current symptoms get worse:
- back pain and stiffness
- pain in a different joint
- damaged nails
- signs of bowel inflammation, like diarrhea and bloody stool
- swollen fingers and toes
- eye pain, redness, and blurred vision
- severe fatigue
Also speak with your doctor about switching treatments if you have X-rays that start to show joint damage, or an ultrasound of joints that shows active inflammation.
As you may already know, biologics can be expensive. Your insurance may not cover all the costs, leaving you with a hefty part of the bill.
If you have insurance, speak with your insurance company about how much they’ll cover for each biologic for PsA. It may turn out that certain brands have lower copays or out-of-pocket costs than other treatments.
There’s also the possibility of switching to an approved biosimilar. This includes etanercept-szzs (Erelzi), adalimumab-atto (Amjevita), or infliximab-dyyb (Inflectra).
Biosimilars are a type of biologic therapy that are similar to biologics that are already approved by the FDA. Biosimilars need to show that they have no clinically meaningful differences from the existing biologic for approval. They’re usually less expensive.
It’s important to consider your preferences and your schedule when choosing a treatment.
Some PsA treatments need to be taken daily. Some biologics are taken once per week, while others are dosed every two weeks or once per month. Ustekinumab (Stelara) only needs to be injected once every 12 weeks after the first two initial doses.
You may prefer treatments that have less frequent dosing regimens if injections or infusions give you anxiety.
The effects of biologics on a developing fetus aren’t fully understood. It’s possible that these medications could result in pregnancy complications.
If you’re pregnant or thinking about becoming pregnant, proceed with caution and stop or switch treatment. Certolizumab pegol (Cimzia) isn’t actively transported across the placenta. This makes it a safer option during pregnancy. It’s now the recommended biologic drug for use during pregnancy or if you’re trying to become pregnant.
PsA is a long-term condition. Your quality of life depends on how you manage the disease with lifestyle changes and medications. While flare-ups may be temporary, it’s still important to treat your condition as a whole. If you’re not happy with your current treatment, talk to your doctor about modifying your treatment plan.