Drug treatmentIf psoriatic arthriti

Drug treatment
If psoriatic arthritis is left untreated, a significant
proportion of patients will develop persistent
inflammation, leading to progressive joint damage
and functional disability (Chang et al 2011).
Therefore, the aim of drug treatment is to control
the inflammatory process. Treatment options
for peripheral joint disease in psoriatic arthritis
include disease modifying anti-rheumatic drugs
(DMAR Ds), anti-tumour necrosis factor (anti-TNF)
therapies, non-steroidal anti-inflammatory drugs
(NSAI Ds) and intra-articular corticosteroids (Box 2).
Patients with mild disease can be managed
successfully with NSAI Ds and local intra-articular
injections of corticosteroids when required.
However, it is important to note that in some
patients, use of corticosteroids may cause a
flare of their psoriasis. Although NSAI Ds and
intra-articular corticosteroids can provide good
symptomatic relief, neither treatment will inhibit
development of structural joint damage (Gottlieb
et al 2008).
If patients require frequent corticosteroid
treatment then introduction of a DMAR D is
indicated. These drugs suppress disease activity
in psoriatic arthritis and include methotrexate,
sulfasalazine, ciclosporin and leflunomide.
Methotrexate, sulfasalazine and ciclosporin may
also have a positive effect on the patient’s psoriasis
as well as moderating joint inflammation.
For patients who do not show an adequate
response to conventional DMAR Ds or
experience unacceptable side effects, anti-TNF
therapy can be considered. Anti-TNF treatments
target TNF alpha, the pro-inflammatory
cytokine responsible for establishment and
maintenance of inflammation in psoriatic
arthritis. It is this overactive inflammatory
response that damages articular bone, cartilage
and soft tissue. There are now four biological
anti-TNF therapies licensed for use in psoriatic
arthritis, including adalimumab, etanercept,
golimumab and infliximab. Although anti-TNF
treatments are expensive compared with
DMAR Ds, evidence and clinical experience
support their cost-effectiveness in the long
term. Studies show that fewer patients receiving
anti-TNF treatments require joint replacement
surgery, and there is a reduced demand on
medical, nursing and therapy services. Patients
also have improved work prospects with reduced
absenteeism (Kimball et al 2007).
The effects of long-term immunosuppressant
DMAR Ds and anti-TNF therapy are significant and
should not be underestimated. The nurse plays an
key role in ensuring the patient is informed fully of
all potential risks associated with these treatments,
in particular the increased risk of contracting
infections and how best to minimise this risk.
Regular blood monitoring is also required to ensure
early detection of neutropaenia or hepatotoxicity.
Monitoring requirements for each drug are available
on the British Society for Rheumatology’s website