Psoriasis and Psoriatic Arthritis Alliance

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1 Psoriasis and Psoriatic Arthritis Alliance A principal source of information on psoriasis and psoriatic arthritis ) Treatments for Psoriatic Arthritis overview Although psoriatic arthritis is a chronic long term condition with no cure, there are many effective treatments to manage and control it. Depending on your individual circumstances your may be offered some of the following different types of treatments. Please note these are listed alphabetically and not in the order use, and is for reference only. (Always follow your health care provider's advice). Biologics Biologics are a recent addition to the clinician s list of prescribable drugs for psoriatic arthritis. They act by copying the effects of substances naturally made by the immune system of the patient. They are manufactured using genetic engineering, meaning that human genes that normally guide the production of these natural human immune proteins (i.e., an antibody to TNF) are used in artificial ways to produce large amounts of a biologic drug. These drugs are given to lessen inflammation by interfering with biologic substances that cause or worsen inflammation. Biologic agents have been approved to treat moderate to severe psoriatic arthritis that has not responded to one or more of the traditional disease modifying antirheumatic drugs DMARDs. They are not generally considered as first-line treatments because of their expense and side effects unless patients are unable to take methotrexate because of side effects or other conditions. Biologic agents may be used alone, but are often given in conjunction with other DMARDs to increase the benefit and limit potential side effects. When patients start biologic agents, they usually also remain on their current dose of non-steroidal anti-inflammatory NSAIDs and/or corticosteroids (i.e., prednisolone) medicines. Currently available biologic agents act as inhibitors of the cytokines, IL-1 or TNF. Cytokines are messenger molecules made by many of the body's cells that act to excite other immune system cells. Interleukin-1 (IL-1) and tumour necrosis factor (TNF) are made in large amounts in rheumatoid arthritis and other forms of inflammation. TNF or IL-1 acts to increase inflammation, similar to the effect of adding petrol to a fire. Hence, these molecules amplify and worsen inflammation and joint damage. Biologic agents specifically attach to TNF or IL-1 and inhibit or inactivate them. Biologic agents are given by injection and usually work quickly to relieve the symptoms and swelling associated with psroiatic arthritis. Although the studies show that most patients will Page 1 of 6

2 improve within 4-6 weeks of treatment, most patients will notice some improvement after the first or second injection. The most common side effects seen with all injectable medicines include skin reactions at the injection site. These occur in less than 30% of patients. These skin reactions may last for between 1 and 2 weeks. The most significant side effect of these medications is an increase the risk of all types of infections, including tuberculosis (TB). Before starting an anti-tnf medication a TB skin test is usually done. Treatment with these agents should be stopped while you have an active infection and are taking an antibiotic or if you have a high fever. People with significant congestive heart failure should not take the anti-tnf agents. Corticosteroids Corticosteroids are synthetic drugs that closely resemble cortisol, a hormone that the body produces naturally. They work by reducing inflammation and the activity of the immune system. They are used to treat a variety of inflammatory diseases and conditions. Examples of corticosteroid medications include cortisone, prednisolone and methylprednisolone. However they should not be confused with the anabolic steroids, which some athletes use to build bigger muscles. Steroids can be given topically, orally or by injection. There are many ways in which they can be injected, depending upon the site of the inflammation. They can be given into a vein or muscle, directly into a joint or bursa (lubricating sac between certain tendons and the bones beneath them) or around tendons and other soft tissue areas. Inflammation is a process by which the body's inner defence mechanisms, the white blood cells and other substances protect the body against infection and foreign invaders such as bacteria and viruses. In certain diseases, however, this immune system doesn't work properly and this may cause inflammation to cause damage by working against the body's own tissues. Inflammation is characterized by redness, warmth, swelling and pain. Steroids reduce the production of inflammatory chemicals to help minimize tissue damage. They also reduce the activity of the immune system by affecting the function of white blood cells. In low doses, steroids may provide significant relief from pain and stiffness for people with psoriatic arthritis. Temporary use of higher doses of steroids may help a person recover from a severe flare-up of the condition. Steroids often are injected directly into joints to treat conditions such as psoriatic arthritis, gout or other inflammatory diseases. They also can be injected into inflamed bursae or around tendons near most joints in the body. Injecting steroids into one or two areas of inflammation allows doctors to deliver a high dose of medication directly to the problem area. When doctors give steroids by mouth or in a vein, they cannot be sure an adequate amount will eventually Page 2 of 6

3 reach the problem area. Injections into a specific joint are generally well tolerated and are less likely than other forms of steroid medications to produce serious side effects. Also, the injections may help avoid the need for oral steroids or increased doses of oral steroids, which could have greater side effects. Steroid injections can be added to other medications including anti-inflammatory painkiller medications and physiotherapy. Whether one or more of these treatment methods are used depends on the nature of the problem. Steroids should not be injected when there is infection in the area to be targeted or elsewhere in the body. Also, if a joint is already severely destroyed, injections are not likely to provide any benefit. If someone has a potential bleeding problem or is taking anticoagulants, steroid injections may cause bleeding at the site. For these people, injections are given with great caution. Frequent steroid injections, more often than every three or four months, are not recommended because of an increased risk of weakening tissues in the treated area. Steroid injections are one of the most effective ways to decrease pain and improve function, yet they generally do not cure the illness. In rare instances, the following side effects might occur: Infection Allergic reactions Bleeding into the joint Rupture of a tendon Skin discoloration Weakening of bone, ligaments and tendons (from excessively frequent, repeated injections into the same area) Not everyone will develop side effects they will vary from person to person. If steroid injections are infrequent (less than every three to four months), it is probable that none of the listed side effects will occur. With oral steroids the occurrence of side effects depends on the dose, type of steroid and duration of treatment. Side effects are much more common with oral medications since they travel around the whole body in the blood stream after being digested through the stomach. Some side effects are more serious than others. Common side effects of steroids include: Skin conditions similar to acne Blurred vision Cataracts or glaucoma An increased tendency for the skin to bruise Insomnia High blood pressure Page 3 of 6

4 Increased appetite & weight gain Increased growth of body hair Lower resistance to infection Muscle weakness Nervousness, restlessness Osteoporosis Stomach irritation Sudden mood swings Swollen, puffy face Water retention, swelling Worsening of diabetes How often any side effect occurs varies from person to person. If steroid use is brief, up to a few weeks, it is possible that none of the listed side effects will occur. The side effects listed generally do not occur when occasional steroid injections are given for arthritis, tendonitis or bursitis?. However, if steroid use involves high doses taken for a few months to several years, an increase in the number of side effects may occur. To minimize the side effects of steroids, doctors follow these guidelines: They prescribe steroids only when necessary. They monitor the patient closely to detect the development of serious side effects. If possible, they use steroid injections for problems in a specific area rather than oral steroids. They use the minimum dose necessary to gain control of the disease. They will reduce the dose gradually as long as the disease remains under control. They will monitor blood pressure often and treat if necessary. They may prescribe calcium supplements to help maintain bone density. Steroids, as with other medications, are not recommended for everyone. In general, people with the following conditions should not take steroids: Infection, Uncontrolled diabetes, Uncontrolled high blood pressure or congestive heart failure, Peptic ulcer, Osteoporosis The decision to prescribe steroids is always made on an individual basis. Your doctor will consider your age, your overall health and other medications you are taking. Your doctor also will make sure you understand the potential benefits and risks of steroids before you start taking them. Disease-modifying anti-rheumatic drugs (DMARDs) If a patient has persistent inflammation in several joints for longer than six weeks then the doctor might prescribe a medication called a Disease Modifying anti-rheumatic Drug or DMARD (pronounced DeeMard). They are usually prescribed in addition to anti-inflammatory NSAIDs as the NSAID is designed to reduce the day-to-day inflammation and the DMARD slows down the biological processes that cause the persistent inflammation. The choice of a specific DMARD will depend upon the type of inflammatory arthritis. Sometimes Page 4 of 6

5 finding the appropriate maintenance dosage can be a matter of trial and error so the response may not be rapid. DMARDs are a diverse class of medications that approach the task of controlling persistent inflammation through different pathways, but each has been proven effective in its own way. The most commonly prescribed are: hydroxychloroquine,, chloroquine, methotrexate, gold therapy, sulfasalazine, azathioprine As much of the damage to joints caused by the persistent inflammation of psoriatic arthritis tends to occur in the first two to three years, clinicians are prescribing DMARDs much earlier than in the past, because the benefits of controlling damaging inflammation far outweigh the risks of reversible side effects. These medications are routinely monitored by your doctor in order to minimise the risks of the side effects.these medications can take up to several months before you begin to feel sustained benefits. Speed of onset of relief isn t the main driver of these medications. Rather, it's the medication's ability to control your symptoms, and your ability to tolerate the medication over a long period of time that is important. The goal is to use the least amount of drug necessary to keep your inflammatory arthritis under control. DMARDs come as tablets, capsules and, in some cases, injections; doses can range from once or twice daily to once a week. As mentioned earlier, your doctor will likely have to adjust your medication from time to time, depending on the results of regular monitoring. The greater benefits offered by DMARDs carry an increased risk of side effects. The vast majority of side effects are rare, and virtually all are reversible by adjusting the daily dose or switching DMARDs. Still, some side effects are common, such as flu-like symptoms, mouth sores, diarrhoea & nausea. Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs inhibit cyclo-oxygenase (COX), the enzyme that converts arachidonic acid to prostaglandins. The reduction in prostaglandin levels provides the analgesic and antiinflammatory properties of NSAIDs, but it is also responsible for side effects, since prostaglandins have a role in protecting the gastric mucosa and maintaining renal blood flow. COX exists in at least two structurally different forms. COX-1, the constitutive form, produces prostaglandins that mediate gastric cytoprotection, renal perfusion and platelet aggregation. COX-2, the inducible form, is activated by inflammatory stimuli and produces prostaglandins that mediate an inflammatory response. Differences in the selectivity of NSAIDs to block the two enzymes may explain why, at equipotent doses, some NSAIDs are more likely to cause side effects than others. Selective COX-2 inhibitors such as celecoxib, etodolac, etoricoxib, lumiracoxib and meloxicam may have less potential to cause gastric and renal side effects than other, non-selective NSAIDs. Like all NSAIDs, the selective COX-2 inhibitors are contraindicated in patients at risk of GI perforations, ulcers and bleeds, but they should be considered in preference to non-selective or standard NSAIDs in patients at high risk of developing serious GI problems, such as those aged 65 and over, those needing prolonged use of standard NSAIDs at maximum recommended doses, those taking other medicines which can cause GI problems, those with a history of GI problems or with serious co-morbidity. Page 5 of 6

6 There is concern about the use of selective COX-2 inhibitors in patients with cardiovascular disease. By decreasing prostacyclin production without reducing thromboxane synthesis (in contrast to aspirin), COX-2 inhibitors may adversely affect the balance between antithrombotic and prothrombotic actions. Consequently, selective COX-2 inhibitors are contraindicated in patients with established ischaemic heart disease, cerebrovascular disease or those with moderate heart failure. Caution needs to be exercised in those with hypertension. For all patients, the balance of gastrointestinal and cardiovascular risk should be considered before prescribing a COX-2 inhibitor, particularly for patients with risk factors for heart disease and those taking low dose aspirin. In all cases, the lowest effective dose of COX-2 inhibitor should be used for the shortest possible time. Selective COX-2 inhibitors are not a substitute for aspirin for cardiovascular or cerebrovascular prophylaxis as they do not inhibit platelet aggregation. Antiplatelet therapies should not be discontinued and, if indicated, should be considered in patients at risk of thrombotic events. All patients on long-term NSAID therapy, particularly the elderly or those with renal, cardiovascular or GI disorders, should be monitored regularly for changes in gastric and renal function. If patients need to be switched from selective COX-2 inhibitors to non-selective NSAIDs, a gastroprotective agent, such as the prostaglandin analogue, misoprostol, an H2- receptor antagonist or proton pump inhibitor should be considered for inclusion in the regimen. Topical analgesics Topical analgesics are creams for the treatment of mild to moderate pain caused by arthritis. These are usually only available on prescription. This article has been prepared by the Psoriasis and Psoriatic Arthritis Alliance and should not be used as a replacement for advice from your doctor. You are strongly advised to speak to your doctor or health care provider if you think you are affected by any conditions or items mentioned in this article. Psoriasis and Psoriatic Arthritis Alliance (PAPAA) P O Box 111, St Albans, Herts, AL2 3JQ, UK Tel: Fax: website: Registered charity no A Company limited by guarantee registered in England and Wales No: Registered office: Acre House William Road, London NW1 3ER Page 6 of 6

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