PsA – Lesson 4 – Talking about psoriatic arthritis treatments

• Research done by leading, independent scientists in rheumatology make up a
  body of “evidence” that guides patients and their rheumatologists in considering and choosing treatments. Evidence-based treatments are those ethically researched through clinical trials or health research studies involving large numbers of patients with PsA. In the case of medications, if the research findings indicate they are safe and effective in clinical trials, they are then approved for use in large populations of patients. Similar types of studies are also conducted on non- medication types of treatment, such as physiotherapy or occupational therapy, and counselling.
• There are 6 major groups of medications which are used to treat PsA. Some medications help control symptoms of the disease while others help control the disease and prevent permanent damage to the joints and complications of PsA.
• Medications to treat only symptoms include:

1. Non-steroidal anti-inflammatory drugs or “NSAIDs”, such as over the counter ibuprofen, (for example Advil® or Motrin IB®), naproxen (or Naprosyn®), diclofenac (or Voltaren® and Arthrotec®).

2. COX-2 inhibitors, such as celecoxib (Celebrex®).

3. Corticosteroids, such as prednisone.

• Medications to treat the underlying disease and symptoms include:

1. Conventional synthetic DMARDs: Disease-modifying anti-rheumatic drugs such as methotrexate, sulfasalazine (Salazopyrin®), leflunomide (Arava®), hydroxychloroquine and azathioprine.

2. Biologic DMARDS:

• • • bsDMARDS: biologic biosimilar DMARDs include adalimumab (Amgevita®), adalimumab (Hadlima®), adalimumab (Hulio®), adalimumab (Hyrimoz®), adalimumab (Idacio®), etanercept (Brenzys®), etanercept (Erelzi®), infliximab (Avsola®), infliximab (Inflectra®), and infliximab (Renflexis®).
    • boDMARDs: biologic originator DMARDs or “biologics”, including adalimumab (Humira®), certolizumab pegol (Cimzia®), etanercept (Enbrel®), golimumab (Simponi ®), infliximab (Remicade®), ixekizumab (Taltz®), secukinumab (Cosentyx®), and ustekinumab (Stelara®), all of which have been approved in Canada and the United States for use in treating psoriatic arthritis.

3. Targeted synthetic molecules (tsDMARDs) include:

• • • Apremilast (Otezla®) and tofactinib cirate (Xeljanz®).
• Biologic DMARDs and targeted synthetic molecule (tsDMARDs) are considered an “advanced therapy”. To learn more about advanced therapies and the process of transitioning to this type of medication, take the JointHealth^TM Education course: Advanced Therapies.
• These medications can work alone or, most often, in combination to reduce the
  pain and other symptoms associated with PsA. As well, a medication called alefacept (Amevive®) is available for treatment of the skin symptoms associated with the disease.
• Non-medication treatments are important, too. They may include an exercise prescription, physiotherapy, occupational therapy, and counselling, among others. These therapy types are all well researched and patients with PsA report that they are instrumental in helping them gain back their quality of life, physically and emotionally.

• Based on results from a recent international survey of patients with PsA, when it comes to treatment plans, PsA patient satisfaction appears high on the surface, but room for growth is still evident. For example 89% of patients said they were satisfied with their current medication but 96% were still experiencing symptoms and 91% would make changes to their PsA medications.

• Research shows that when patients with PsA agree with their rheumatologist on their diagnosis and treatment prescription, they actually do better on the treatment. Finding agreement on and having confidence in your treatment plan increases your willingness to follow (also called “adherence”) the treatment plan, and as a result, get better.

• A very important research finding is that patients with PsA define treatment success as no longer being in pain and seeing improvement in their quality of life. Rheumatologists think success is getting your disease into remission or at least low disease activity. They are one in the same, really. The treatment goals of disease remission or the lowest disease activity possible results in less or no pain and big improvements in quality of life.

• Rheumatologists generally follow treatment guidelines supported by ethical research over the past 50 years. The latest American College of Rheumatology PsA Guidelines recommend the following approach for patients starting medication treatment:

Step 1: A person newly diagnosed with PsA may be initially given non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin® or Advil®), naproxen (Aleve®).

Step 2: If their disease does not to respond to the NSAID’s, the PsA patient
may be prescribed one or multiple disease modifying anti-rheumatic drugs (DMARDs).
These include sulfasalazine, methotrexate, cyclosporine and leflunomide. Sometimes hydroxychloroquine may be prescribed, but it is usually avoided as it can cause a flare of psoriasis. Patients with severe forms of PsA may be prescribed azathioprine.

Step 3: If the PsA does not respond or does not respond well enough to the above combination therapy (i.e. the patient’s inflammation is not well controlled), a targeted synthetic molecule or biologic DMARD should be started and can be taken by infusion or injection. There are several biologic DMARDs that can treat PsA and/ or psoriasis; with their doctor, a patient will determine which is best for them. If the biologic is not working well enough, a patient may try a different one.

• The first 3 months of medication therapy monitoring are important for both you and your rheumatologist. Starting your medication treatment as early as possible after diagnosis (the “window of opportunity”), increasing the doses quickly if required, and adding therapy, etc.

• The fear of side effects sometimes keeps patients with PsA from taking their medication as prescribed, or at all. Concern over side effects is understandable, but the most important things to know about side effects are these:

  • Untreated or undertreated PsA poses a greater threat to you, your joints and your long-term health and well-being than most medication side effects.

  • The most common side effects of PsA medications are the least serious, and the most serious side effects occur very rarely.

  • Most side effects from PsA medications can be managed by temporarily stopping it, or decreasing the dose and slowly increasing it again to the appropriate dose strength.

• Until scientists find a way to permanently “shut off” the auto immune response that keeps PsA active in your body, sticking with the medication and non- medication treatments that make up your treatment plan is very important to maintaining disease control and your quality of life.

• In a recent global survey of PsA patients, about one quarter of patients with PsA report that they were not taking their medication exactly as prescribed. The most common reasons given for not taking their medication as prescribed were forgetting to take the medication, and inconvenience, followed by wanting to avoid side effects.

• Some strategies to remind you to take your prescribed medication include:

  • setting an alarm on your phone or watch

  • putting medication in a spot you will see each day and tying it into a daily activity you already do (e.g. putting the medication beside your bathroom sink and taking it after you brush your teeth)

  • asking your partner or family member to remind you

• Understanding the side effect profile of your medication(s) is important but should not cause you to fear taking it.

• You play an important role in monitoring the effectiveness of your treatments and progress against your treatment plan. You live with your disease every moment of every day, and the improvements or worsening of your symptoms can best be judged by you.

• As part of your treatment plan, keep a journal that records symptoms and important quality of life measures such as your sleep patterns, ability to do daily tasks, attend work regularly, participate in leisure activities and sport, and other things that you feel are important measures of how well (or not) you are doing. The benefits of keeping a PsA journal are well documented by research.

• You will probably be asked to go to a lab for regular blood tests, monthly to begin with and then every two or three months as directed by your rheumatologist. Many patients with PsA ask for copies of their lab tests so that they can include the results in their journal. Normal or improving lab tests can motivate you to continue following your treatment plan because you see the positive results in black and white and are assured there are no negative effects of taking the medications.

• Another helpful strategy is to ask those who live with you or see you every day what they notice about your symptoms. Sometimes those around us are able to notice disease patterns that we don’t see ourselves.