Psoriatic arthritis (PsA) is an inflammatory rheumatic condition usually associated with skin and/or nail psoriasis. The articular manifestations are quite heterogeneous, with arthritis being the most frequent manifestation, but with enthesitis, dactylitis and/or spondylitis occurring in a relevant proportion of patients. Extra-articular manifestations, such as uveitis or inflammatory bowel disease, also occur in a higher frequency compared to the general population, supporting the inclusion of PsA in the clinical spectrum of spondyloarthritides. It has been shown that PsA can have a profound impact on quality of life, because of the different clinical disease manifestations as well as the psychological and social consequences. All these aspects make PsA a disease which may be difficult to manage in the daily clinic. In the past treatments of PsA were largely based upon therapies “borrowed” from rheumatoid arthritis (RA). Recently EULAR has developed evidence-based guidelines for the management of PsA: these consist of a number of overarching principles, as well as specific recommendations to guide treatment with NSAIDs, synthetic DMARDs and biologicals. The level of evidence supporting each recommendation was graded by a Task Force based upon a systematic review of published literature. Despite the evident lack of well-designed controlled clinical trials, conventional DMARDs such as methotrexate are still widely used by rheumatologists to treat PsA. Upon failure of this therapeutic option, approved anti-TNF agents, such as etanercept, adalimumab, infliximab and golimumab, have been shown to improve dramatically the outcomes for patients, often tackling both the rheumatological and the dermatological aspects of the disease. In case of failure of these treatments, a number of new agents have been studied or are in development for PsA: these include treatments approved for RA (abatacept), psoriasis (ustekinumab), or newer agents targeting e.g. IL-17. Small oral molecules such as apremilast or tofacitinib are also in development. Data on these different options will be discussed, providing an indication of what this could mean for current and future clinical practice.
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