Psoriatic Arthritis (cont.)

Disease-Modifying Medicines

Patients who experience progressive joint destruction in spite of NSAIDs are candidates for more aggressive disease-modifying medications. Disease modifying medications are important to prevent progressive joint destruction and deformity. These medications include methotrexate, which is used orally or can be given by injection on a weekly basis for psoriatic arthritis as well as for psoriasis alone. It can cause bone-marrow suppression, as well as liver damage with long-term use. Regular monitoring of blood counts and liver blood tests should be performed during therapy with methotrexate.

Antimalarial medication such as hydroxychloroquine (Plaquenil) is also used for persistent psoriatic arthritis. Its potential side effects include injury to the retina of the eye. Regular ophthalmologist examinations are suggested while using this medication.

Injectable gold (Solganol) and oral gold auranofin (Ridaura) have potential side effects including bone-marrow suppression which can lead to anemia and low white blood counts and adverse effects on the kidney, causing loss of protein or blood in the urine.

Sulfasalazine (Azulfidine) is an oral sulfa-related medicine that has also been helpful in some patients with persistent psoriatic arthritis. Traditionally, Azulfidine has been an important agent in the treatment of ulcerative and Crohn's colitis. It should be taken with food, as it too can cause gastrointestinal upset.

Research has demonstrated effective treatment of both psoriasis and psoriatic arthritis with leflunomide (Arava), a medication that was approved in 1998 for the treatment of rheumatoid arthritis.

The TNF-blockers etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) can be very effective for severe psoriatic arthritis and they can significantly improve or eradicate both the psoriasis and the arthritis as well as stop progressive joint damage.

Corticosteroids are potent anti-inflammatory agents. Corticosteroids can be given by mouth (such as prednisone) or injected (cortisone) directly into the joints to reduce inflammation. They can have side effects, especially with long-term use. These include thinning of the skin, easy bruising, infections, diabetes, osteoporosis and, rarely, bone death (necrosis) of the hips and knees.

While the relationship between the skin disease and joint disease is not clear, there are reports of improvement of the arthritis simultaneously with clearing of the psoriasis. Patients with psoriasis can benefit by direct sunlight exposure and are often treated with direct ultraviolet light therapy.

Finally, patients who have severe destruction of the joints may be candidates for orthopedic surgical repair. Total hip joint replacement and total knee joint replacement surgery are now commonplace in community hospitals throughout the United States.

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