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How to Treat Both Joint and Skin in Psoriatic Arthritis
Table 1: Treatment Options for Different Features of Table 2: Adverse Reactions Associated with Drugs Used to Treat
Psoriasis and Psoriatic Arthritis Psoriasis and Psoriatic Arthritis
Skin Peripheral Axial Enthesitis Dactylitis Drugs Adverse Reactions
Disease Arthritis Disease NSAIDs Gastrointestinal bleeding, dyspepsia, renal toxicity,
NSAIDs - + + +/- +/- high blood pressure, fluid retention
Corticosteroids Topical + +/- Injection +/- Corticosteroids Pustular psoriasis flare, fluid retention, Cushing’s syndrome,
Methotrexate + + - +/- +/- obesity, osteoporosis, increased blood pressure, hirsutism
Sulfasalazine + + - - +/- Methotrexate Abnormal liver tests, granulocytopaenia, pneumonitis,
Mesalazine + + - - +/- mouth ulcers, hair loss, teratogenicity, lymphoma (?)
Leflunomide + + - +/- - Sulphasalazine Abnormal liver tests, diarrhoea, nausea,
Cyclosporine A + + - - - granulocytopenia, rash, azoospermia
Anti-TNFα agents + + + + + Leflunomide Abnormal liver tests, granulocytopaenia,
NSAIDs = non-steroidal anti-inflammatory drugs; TNFα = tumour necrosis factor α.
thrombocytopaenia, diarrhoea, nausea,
rash, hair loss, polyneuropathy
Cyclosporine A Renal toxicity, high blood pressure, hirsutism,
Significant improvement was observed on pain in the peripheral joints gum hyperplasia, nausea, malignancy
and spine, morning stiffness and skin disease. In addition, reduction of Anti-TNFα agent Infection including tuberculosis reactivation,
histological inflammatory cells and molecules was observed in an
infusion side effect, demyelination, congestive
open-label study that included eight patients with knee synovial
cardiac failure, abnormal liver tests, leucocytopaenia,
drug-induced lupus and psoriasis, malignancy (?)
biopsy.
37
The Infliximab Multinational Psoriatic Arthritis Controlled
NSAIDs = non-steroidal anti-inflammatory drugs; TNFα = tumour necrosis factor α.
Trial (IMPACT) has established the efficacy of infliximab for PsA
patients.
38,39
ACR criteria 20, 50 and 70 were achieved by 65, 46 and
29%, respectively, of patients treated with infliximab compared with Recently, Heiberg et al. conducted a longitudinal, multicentre,
10, 0 and 0%, respectively, of patients receiving placebo. observational study that suggested that the clinical improvement
Furthermore, infliximab was effective at treating dactylitis, enthesitis appeared to be superior in patients treated with the aTNFα compared
and skin rash. At 24 weeks, infliximab inhibited radiological with MTX monotherapy.
15
progression. Evaluated with EQ-5D and HAQ, infliximab significantly
improved both quality of life and physical function.
40
Another open- The safety profile of TNF-targeted therapies is reasonably good.
label study of 15 patients demonstrated a highly significant effect on Potentially adverse reactions related to aTNFα in the management of
both skin and joints,
41
and also provided an insight into the psoriasis and PsA are comparable to those described previously for RA
mechanism of action of TNFα blockade reducing cell infiltration, patients.
2
aTNFα interferes with normal immunological reactions and
proliferation and angiogenesis in psoriasis skin biopsies. increases risk of infection. Screening for latent tuberculosis is
recommended before starting the medication. There are still some
Adalimumab (Humira™) is a fully human aTNFα monoclonal antibody controversies regarding the risk of malignancy: although registry data
administered as a subcutaneous injection of 40mg every other week. thus far show no increased incidence of solid-organ tumours, the risk
A large placebo-controlled study – Adalimumab Effectiveness in of skin cancers remains a potential concern.
43
Other infrequently
Psoriatic Arthritis Trial (ADEPT) – was conducted in 313 PsA patients.
42
described side effects include cytopaenia, hepatitis, drug-induced skin
rash or lupus, worsening of cardiac failure and demyelinising disease.
2
Conclusion
Evaluated with health-related EuroQol
A number of systemic drugs – both conventional and biologic
and Health Assessment Questionnaire,
therapies (see Table 1) – are now available and appear to be useful in
the management of both the skin and joint manifestations associated
infliximab significantly improved both
with psoriasis and PsA. The choice of medication may still depend
quality of life and physical function.
predominantly on the clinical presentation and the specialist first
consulted; however, agreement between skin and joint specialists
is growing.
As with other aTNFα, at 24 weeks adalimumab was statistically more The primary aims of therapy are to control disease activity, improve
effective compared with placebo. ACR criteria 20, 50 and 70 response function and – possibly the most critically important – prevent joint
rates were 57, 39 and 23%, respectively, in the adalimumab arm and damage. More recent studies include a direct benefit in terms of
15, 6 and 1%, respectively, in the placebo arm. Results for PsARC quality of life data for psoriasis and PsA patients. New and increasing
response rates and improvement of enthesitis and dactylitis were not interest is developing regarding the possible cost-effectiveness
statistically significant; this also applied to radiological progression measures of the biologic therapies.
prevention and functional assessment. There was a rapid and
significant improvement on the skin, starting at two weeks. In routine clinical practice it is recommended to begin taking DMARDs
when patients fail symptomatic, topical or NSAID treatment. One
When allowed in the protocol of the previously mentioned studies, possible exception to this is predominant axial involvement. As
co-medication with MTX did not provide any extra advantage.
32,42
DMARDs do not show any efficacy on spinal and sacroiliac disease, it
EUROPEAN MUSCULOSKELETAL REVIEW 2007 23
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