The first few months after a psoriatic arthritis diagnosis can be tricky as you and your doctor figure out which medications are most effective for you. It’s often a trial-and-error process that may involve starting a new medication or adding one to your treatment regimen. “The start of psoriatic arthritis treatment is the most trying time,” says Elyse Rubenstein, MD, a rheumatologist at Providence Saint John’s Health Center in Santa Monica, California. “You’re trying to find out what will put you in remission. But even after you’re in remission, there’s a chance the disease could flare, and you could need to switch medications again.” There’s no set treatment for this condition — the medication that works well for one person might not be effective for someone else. Even the drug for psoriatic arthritis that works for you now might not be as successful in a few months. A study published in Arthritis Research & Therapy examined the treatment patterns of people with psoriatic arthritis who initiated therapy (started a medication for the first time) with a biologic or nonbiologic disease modifying antirheumatic drug (DMARD). Investigators found that 69 percent of people who began treatment with a nonbiologic DMARD such as methotrexate or sulfasalazine (Azulfidine) altered their medication regimen within a year. About 45 percent of those who took biologic drugs for psoriatic arthritis like infliximab (Remicade) and adalimumab (Humira) did the same. If you can manage your pain with an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen (Advil, Motrin), you might not need prescription medication, she says. In cases where an NSAID isn’t enough, another option could be a nonbiologic DMARD like methotrexate. For more severe symptoms, a biologic drug could be the answer. If you have other health conditions, your doctor will also take those into consideration. For example, people with high blood pressure need to be monitored for increased hypertension if they take NSAIDs, according to the Cleveland Clinic. Individuals with congestive heart failure or those who have a family history of demyelinating diseases, such as multiple sclerosis and Guillain-Barre syndrome, may want to avoid certain biologic medications, Rubenstein says. Other considerations include any medication allergies you may have and your level of comfort with non-oral drugs. Many drugs for psoriatic arthritis are given via injection or intravenously. You haven’t reached your treatment goals. If you’re taking a medication and still experiencing signs of psoriatic arthritis, it might be time to try something else. “Are you able to carry out the activities of daily living? Are you able to go to work?” Rubenstein asks. “Daily function is one of the things to look at.” One way to measure if your psoriatic arthritis medication is doing what it should is a strategy called Treat-to-Target (T2T), according to the Arthritis Foundation. In T2T, the doctor sets a predetermined treatment goal, which is usually remission or very low disease activity, and then evaluates the patient periodically (usually every three to six months) to see if they’ve reached the goal. If they haven’t, the physician may increase the medication dose, try a different drug of the same type, or switch to a different drug class altogether. In treating psoriatic arthritis, it’s important to note that two drugs aren’t always better than one. Results of a large, ongoing trial, published in the journal Rheumatology in April 2020, found that on average, using methotrexate for psoriatic arthritis in addition to ustekinumab (Stelara) or a tumor necrosis factor inhibitor (TNFi) didn’t improve the ability of patients to reach their composite treatment targets. You’re experiencing side effects. Some psoriatic arthritis medications may cause side effects that are bothersome enough to require discontinuing the drug. Side effects may include gastrointestinal irritability, nausea, headaches, and rashes, Rubenstein says. People who take a medication that suppresses the immune system may develop an infection, making it necessary to stop the drug. A study published in the journal Mediators of Inflammation found that almost 40 percent of people who discontinued their biologic drugs during the study did so because of side effects. However, medications should never be stopped without first consulting your doctor, who can determine the cause of any side effects and adjust your treatment plan accordingly. You’re not taking the drug properly. It can be difficult to follow a medication schedule, says Ellen Amanda Snyder, MD, assistant professor of medicine in the division of rheumatology, allergy, and immunology at the UNC School of Medicine in Chapel Hill, North Carolina. Remembering what you need to take and when you need to take it while also managing work, family, friends, and other commitments isn’t easy, though it does make a real difference, she says. “I find that patients do best when they are able to really focus on taking their medications as prescribed,” says Dr. Snyder. If that’s something you struggle with, talk with your doctor. They may be able to suggest ways to help you adhere to your medication schedule or switch you to a treatment that’s easier for you to manage. Talk to your doctor about the risks and benefits of your treatment. A study published in December 2016 in Clinical Rheumatology found that some people with mild psoriatic arthritis symptoms were willing to risk relapse rather than suffer from medication side effects such as severe nausea. People with psoriatic arthritis should also remember that the goal of treatment is remission — meaning no arthritis pain and the ability to perform tasks like walking, working, and exercising with little or no trouble. If a medication alleviates only some of your pain, it’s not working properly. “You want to be functional,” Rubenstein says. “Some people might have five minutes of morning stiffness but then they’re fine, and that’s okay. But if you’re having three hours of morning stiffness every day, something’s wrong.” Additional reporting by Becky Upham.
