Medications that doctors typically use to control psoriatic arthritis are known as disease-modifying anti-rheumatic drugs (DMARDs). A wide variety of medications fall under this umbrella, both traditional medications and newer ones. The newer drugs — called biologics — target specific parts of the immune system to help stop the inflammatory process that leads to psoriatic arthritis. Biologics have been available since 2005, and today there are several types to choose from. Each target different pathways thought to cause psoriatic arthritis. Both traditional DMARDs and biologic therapies are used to treat psoriatic arthritis because they not only reduce pain and inflammation but can also help prevent joint damage. In other words, they relieve symptoms as well as help slow or stop the processes in the body that lead to inflammation. However, biologic therapies may be better at this than traditional DMARDs. Studies that have compared biologics to the traditional DMARD methotrexate have found that response to treatment was similar, but biologics were significantly better at preventing joint damage seen on X-rays. Biologics also have the advantage of starting to work quickly. You may see a reduction in pain and swelling after the first few treatments, whereas traditional DMARDs can take up to six weeks or longer to provide results. People with psoriatic arthritis may have higher-than-normal levels of tumor necrosis factor-alpha (TNF-alpha), a protein that triggers inflammation in psoriatic arthritis and other inflammatory autoimmune diseases. Biologics that block the action of this protein are called TNF-alpha inhibitors. There are five TNF-alpha inhibitors approved to treat psoriatic arthritis:
AdalimumabCertolizumab pegolEtanerceptGolimumabInfliximab
Interleukin-12, interleukin-17, and interleukin-23 are other proteins that activate the inflammation of psoriatic arthritis. Biologics approved to block these proteins are:
IxekizumabSecukinumabUstekinumab
Another biologic, abatacept, prevents T-cells — white blood cells involved in the inflammatory process — from being activated, helping to reduce inflammation. In the treatment of psoriatic arthritis, biologics may be taken alone or in addition to a traditional DMARD. Several studies have shown that a biologic drug combined with the DMARD methotrexate works better than either drug works alone.
When to Consider Biologics for Psoriatic Arthritis Treatment
The guidelines doctors follow when prescribing biologic treatment call for their patients to have:
Active arthritis despite treatment with two of the traditional DMARDsVery active arthritis or evidence of joint damage despite treatment with one DMARDActive psoriatic arthritis in the spine
“The choice of when to start or add a biologic and which biologic to use comes down to a decision made between you and your doctor," says Rochella Ostrowski, MD, a rheumatologist and an assistant professor of allergy, immunology, and rheumatology at the Loyola University Stritch School of Medicine in Maywood, Illinois. “All biologics are given by injection or intravenous infusion, but some are given more often than others. Some people may want their disease treated more aggressively. All of these factors come into play when deciding on a biologic.”
What You Need to Know Before Starting a Biologic
Although biologic therapies can be effective in treating psoriatic arthritis, there are two main reasons your treatment may start with a traditional DMARD: cost and the risk of infection. According to an article published in November 2018 in the journal Drugs, biologics can cost between $10,000 to $30,000 per year on average and up to $500,000 per year for the most expensive options. The good news: Most insurance companies cover at least a portion of that. Talk to your health insurance carrier about coverage and ask your doctor about a prescription assistance plan either through the hospital or the drug manufacturer. Biologics are generally considered safe, but because they work by suppressing the immune system, they may increase your risk of infections. Your doctor can help you monitor these risks. Biologics may also reactive latent tuberculosis and hepatitis B and C infections, so you will need to be tested for these before starting treatment. Once thought to increase your risk of cancer, a study published in March 2020 in The Lancet Gastroenterology and Hepatology that looked at more than 8,000 patients with psoriatic arthritis who use TNF-inhibitors found no link between these drugs and a person’s risk of lung, melanoma, pancreatic, brain, endometrial, and breast cancer. The researchers did find a link between TNF-inhibitors and lymphoma, although more investigation is needed to determine why. “You may not be able to take a biologic if you have active tuberculosis, multiple sclerosis, or recent cancer, or if you may become pregnant,” Dr. Ostrowski says. “If you start a biologic and you get an infection, you may have to stop treatment until the infection is under control.” Because these drugs are given by injection or intravenously, injection site reactions are a common, though minor, side effect. For injectable drugs, you may need to learn how to administer them yourself. Common places for injections are the thigh and belly, and rotating the injection site can reduce site reactions. More factors to consider about biologic therapy for psoriatic arthritis include:
Because of the possibility of an infection from contaminated food, you need to avoid uncooked or undercooked eggs and meat and carefully wash all fruits and vegetables.If you test positive for tuberculosis, hepatitis, or the human immunodeficiency virus (HIV) before treatment, these infections must be treated or under control before you start a biologic.You may not be able to take these drugs if you have severe heart failure.Talk to your doctor before getting any vaccines.
“Another important thing to know is that you can build up antibodies to [biologics] and this can make them less effective,” Ostrowski says. “You can’t take more than one of these drugs at a time, but if one becomes less effective, you can switch to another.”
Always a Priority: Healthy Lifestyle Habits
No matter what medications you’re using to treat psoriatic arthritis, healthy lifestyle changes also should be part of your treatment plan. Maintaining a healthy weight, getting regular exercise, eating a healthy diet, not smoking, and keeping alcohol consumption in moderation are all important. Incorporating these healthy lifestyle habits into your psoriatic arthritis treatment plan can enhance your overall well-being. Deciding to use a biologic for psoriatic arthritis treatment is a big decision for you and your doctor. Although it won’t cure the disease, this drug therapy can help reduce symptoms, prevent joint damage, and improve your quality of life. With additional reporting by Marie Suszynski and Susan Jara
