How Are DMARDs Used to Treat Psoriatic Arthritis?

From healthcentral.com

These disease-modifying medications can be highly effective, with a few considerations 

DMARDs (disease-modifying anti-rheumatic drugs) are used in psoriatic arthritis (PsA) treatment to reduce inflammation, slow joint damage, and improve symptoms like pain and stiffness. If your doctor has prescribed a DMARD as part of your treatment plan, you probably have some questions about what DMARDs are, how they work, and whether there are any side effects to worry about. Here’s what you need to know.

How DMARDs Work for Psoriatic Arthritis

DMARDs are often referred to as immunosuppressants or immunomodulators because they change the way your immune system works. In simple terms, when you have psoriatic arthritis, your immune system goes off track and mistakenly attacks your body’s healthy tissues. While the exact mechanism of action is still being explored, scientists believe that DMARDs target at least one inflammatory pathway, helping to tamp down uncontrolled inflammation.

Unlike commonly used over-the-counter medications such as non-steroidal anti-inflammatory drugs (NSAIDs), DMARDs can reduce the symptoms of psoriatic arthritis while also slowing down the disease to prevent further damage.

Types of DMARDs Used for Psoriatic Arthritis

Historically, when you think about DMARDs for psoriatic arthritis, you are usually referring to conventional systemic DMARDs (such as methotrexate), according to Laura Coates, Ph.D., an associate professor and researcher of psoriatic arthritis at the University of Oxford in England.

Because newer classes of PsA medications (such as biologics) are also disease-modifying and anti-rheumatic, you may also see biologic medications denoted as bDMARDs. In addition, some of the newer targeted synthetic medications are denoted as tsDMARDs (apremilast, tofacitinib). “I think of the targeted synthetic DMARDs as being more similar to biologics than to methotrexate as far as cost, novelty, and effectiveness,” Coates says.

The list of conventional DMARDs that are commonly used for psoriatic arthritis include:

• Arava (leflunomide)

• Azulfidine (sulfasalazine)

• Cyclosporine and Tacrolimus (calcineurin inhibitors)

• Rheumatrex, Trexall, Rasuvo, Otrexup (methotrexate)

Which DMARD Is Right for Your Psoriatic Arthritis?

                                                  Getty Images/WLADIMIR BULGAR/SCIENCE PHOTO LIBRARY

Which treatment is right for you will be a decision based on close collaboration between you and your provider. It depends on a variety of factors, according to Elizabeth Schulman, M.D., attending physician at the Hospital for Special Surgery and an assistant professor of medicine at Weill Cornell Medical College in New York City. “Today, the first line of treatment for PsA is biologics for most cases,” says Dr. Schulman. “We really only use methotrexate as a first line of treatment when it is contraindicated, for example if someone is fearful of the side effects of a biologic, or if there is a comorbidity that would prevent them from using a biologic.”

The choice of medications can also depend on the specifics of your disease. “As an example, methotrexate is not approved for axial disease [inflammation related to the spine],” explains Dr. Schulman.

Costs may also come into play in the decision-making. For example, conventional DMARDs are often less expensive than the new biologics that are available. And patient preference matters. DMARDs can be taken as a pill, which can be helpful for those uncomfortable with injections. According to Dr. Schulman, “DMARDs are not our usual standard of care, but they are still in our toolbox.”

Side Effects of DMARDs

“All drugs have significant specific side effects and DMARDs are no exception,” says Coates. For example, DMARDs can lower the ability of your immune system to fight infections. According to the American College of Rheumatology, other side effects of DMARDs include:

• Abnormal blood counts

• Diarrhoea

• Dizziness

• Elevated liver function tests

• Gastrointestinal upset

• Hair loss

• Hypertension

• Mouth sores

• Rash

What if the DMARD You're On Isn't Working?

If your DMARD isn’t providing symptom relief, talking to your provider is a great first step. Even if you are experiencing side effects, your provider may be able to adjust your dose or timing of your medication or add a supplement (such as folate) to help reduce the side effects.

How long do you need to wait to decide if it is working? According to the National Psoriasis Foundation, if you don’t meet your target goal with your treatment in three months, it’s time to discuss other treatment options with your doctor. If you do need to change treatment, don’t worry, there are more therapies available than ever before for psoriatic arthritis.

Takeaways

Disease modifying antirheumatic drugs (DMARDs) have been a cornerstone of psoriatic arthritis treatment for many years. Due to their long history, they are often called traditional or conventional DMARDs. There are newer disease modifying medications now available and those are also sometimes referred to as disease modifying drugs, but they are often denoted as bDMARDs or tsDMARDs.

There are known side effects of traditional DMARDs but these are also well-understood medications. If you are prescribed a DMARD and it isn’t working for you, there is always the option to change medications or add a new treatment to the one you are taking. Your provider will help you understand the benefits and risks of all your medications. Together you will decide the best treatment for you.

https://www.healthcentral.com/condition/psoriatic-arthritis/dmards-for-psoriatic-arthritis