Learn how to get psoriatic arthritis under control and keep it
that way
| By Alex Hess
Getting psoriatic arthritis (PsA) under control and achieving
remission is possible with currently available medications. Up to 60 percent of
patients with PsA compared to 44 percent of patients with rheumatoid arthritis
are able to achieve minimal disease activity at one year of treatment with
biologics, according to a study published in 2010 in Arthritis
Research & Therapy.
Psoriatic
arthritis is a form of inflammatory arthritis that affects both skin and
joints. It is treated with disease-modifying antirheumatic drugs (DMARDs) and biologic drugs. In some cases, these drugs can lead to
a near disappearance of symptoms, prompting patients to wonder if they still
need their medication. But remission does not equal cure.
How Can I Reach Remission?
Some
people may have a very mild form of PsA and get it under control relatively
quickly, whereas others may have very severe disease and have to try several
medications and combinations of medications to find relief. There are no clear
criteria for defining remission in PsA, so it is difficult to say when you have
gotten there. In general, rheumatologists talk about getting to “a minimal
disease activity state.”
One of
the best ways to help achieve low disease activity is through close
collaboration with your rheumatologist.
“After
a patient starts on a medication, we follow the patient closely, especially in
the initial period. We re-evaluate their symptoms, examine their
laboratory findings and then make adjustments to the medication accordingly,”
says Soumya Reddy, MD, assistant professor of medicine at New York University
Langone Medical Center and co-director of its Psoriasis and Psoriatic Arthritis
Center. “So if a patient is not responding adequately, you have an opportunity
to change or increase the dose of their medication.”
The
standard of care in psoriatic arthritis is moving toward a treat-to-target (T2T) strategy. Treat-to-target is any
strategy where you have a pre-specified management approach to achieve a target
outcome.
“It’s
typically a target that patients and physicians feel is meaningful and
something that patients would be satisfied to attain,” explains Dr. Reddy. “In
T2T, doctors may see patients every 4 weeks with a very clear guideline about
how to escalate treatment and change therapy if the patient has not yet reached
minimal disease activity. In a ‘usual treatment’ protocol, patients are seen
less often, maybe every 12 weeks, and the change in treatment happens based on the
preference of the patient and physician at that time. This leads to a slower
escalation of therapy compared to T2T strategy, and thus potentially slower
achievement of low disease activity.”
Can I Stop My PsA Medication When I Feel Better?
Once
you reach a state of low disease activity, rheumatologists recommend you
continue on your medications. If you take more than one medication or if your
medication comes in different doses, your doctor can try taking you off of one
medication, or lowering the dosage.
“I
generally don’t recommend treatment discontinuation for my patients,” says Dr.
Reddy. “It’s a common question and a question that many patients are interested
in. But in my experience, most patients will have a recurrence or a flare
within a few months of discontinuing medication. For some patients that can be
as early as two weeks, but sometimes it can be as late as six months to a year.
If patients wish to try discontinuing the medications after being in a minimal
disease activity state for a prolonged period of time, we work with them and
follow them closely during this period. The key is to get them back on
medication as soon as they start getting a recurrence.”
According
to a small study published online in 2013 in the journal BMJ, about 75 percent of patients had a recurrence
within six months of stopping medication and most of them flared within the
first two to three months. It appears that though the disease may quiet down
during remission, it doesn’t cease to exist.
“I
think that that’s what patients should be aware of before they embark on the
trial of discontinuation of drugs,” notes Dr. Reddy. “Although there are some
patients that I see who are able to discontinue medication and go into
prolonged periods of remission, it’s not the common scenario,” she cautions.
Patients
who have more consistent, longer duration of disease and patients who have more
severe disease are at the highest risk of recurrence. Another risk factor is
male gender and evidence of some clinical inflammation on ultrasound.
Can Early Aggressive Treatment Help Achieve Remission?
Starting
treatment for psoriatic arthritis as early as possible could, in theory, make
lasting remission more likely. Patients with psoriatic arthritis can develop
significant damage early in their disease. Unfortunately, many people with
psoriasis are unaware they also have PsA, and many patients are undertreated. By treating early, joint damage can be
prevented, leading to improved long-term outcomes.
“A
patient with PsA for 10 years may have already accumulated some amount of joint
damage and possibly deformities limiting the function of their joints. So if
you treat them at that point, they may still see significant improvement from
treatment, but damage to the joints that has already occurred cannot be
reversed,” explains Dr. Reddy.
Although
some PsA patients may be frustrated by the need to stay on medication,
remission is far better than no remission. One thing to remember is that while
these medications work, they don’t cure the disease. “Patients sometimes ask,
‘I’m feeling great, I don’t have any psoriasis, I don’t have any joint pain,
can I just stop my medication?’ Because they feel that they are cured. And
that’s a testament to the highly effective medications we have these days,”
says Dr. Reddy. “Sometimes after four years, you forget how you felt before,
how affected your joints and your skin were prior to being on the medications.”
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