Unlike nonsteroidal anti-inflammatory drugs (NSAIDs), which primarily relieve the pain, swelling, and stiffness associated with psoriatic arthritis, immunosuppressant medications can help prevent permanent joint damage, according to the National Psoriasis Foundation. (Note: Although you can buy some NSAIDs like ibuprofen without a prescription, always talk with your doctor before you begin using them.) Francis C. Luk, MD, a rheumatologist at Wake Forest Baptist Health in Winston-Salem, North Carolina, says that immunosuppressants can counter the potentially harmful effects of cytokines — small proteins produced by the immune system that fight infection and trigger inflammation. “If we can block some of these, it can help control the psoriatic arthritis and even prevent bone and joint damage,” Dr. Luk says.
Types of Immunosuppressants
Commonly prescribed immunosuppressant drugs for psoriatic arthritis include: TNF inhibitors (tumor necrosis factor-alpha inhibitors) TNF inhibitors or blockers are part of a class of drugs called biologics, which are protein-based drugs that mimic the effects of naturally occurring substances found in the body. “TNF is one of those molecules that’s released by our immune cells and basically it leads to inflammation, swelling, and pain,” Luk says. For people with psoriatic arthritis, “blocking this molecule can often lead to relief,” he adds. Medications in this category include adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade). Psoriatic arthritis treatment guidelines by the American College of Rheumatology and the National Psoriasis Foundation recommend these medications as first-line therapy, ahead of methotrexate, for psoriatic arthritis. Interleukin inhibitors Biologic therapies for psoriatic arthritis block different proteins that activate psoriatic arthritis inflammation. These include ixekizumab (Taltz), which inhibits IL-17; secukinumab (Cosentyx), an IL-12 inhibitor; and ustekinumab (Stelara), an IL-23 inhibitor. Abatacept (Orencia) The biologic abatacept blocks the activation of T cells (white blood cells involved in psoriatic arthritis inflammation) to reduce pain and swelling. Methotrexate (Rheumatrex, Trexall) “Methotrexate is helpful for both psoriasis and the arthritis associated with psoriasis,” says Evan Siegel, MD, a rheumatologist with Arthritis and Rheumatism Associates in Rockville and Wheaton, Maryland, and an assistant clinical professor of medicine at Georgetown University School of Medicine in Washington, DC. Methotrexate for psoriatic arthritis involves a once-a-week dose, either orally or by injection. While there’s not a lot of clinical trial data supporting the use of methotrexate for psoriatic arthritis, Dr. Siegel says that physicians have been utilizing it successfully for more than 30 years. About half of people with psoriatic arthritis respond to methotrexate, according to Lenore Buckley, MD, MPH, a rheumatologist and a professor of medicine at Yale School of Medicine in New Haven, Connecticut. Janus kinase (JAK) inhibitor This medication can help calm the immune system by blocking certain enzymes that can cause inflammation, according to Luk. The approved medication to treat psoriatic arthritis in this category is tofacitinib (Xeljanz and Xeljanz XR). Leflunomide (Arava) If you can’t tolerate methotrexate or can’t take it for other health reasons, your doctor may try leflunomide. “It has been moderately helpful for the joints in clinical trials,” says Siegel. He adds that about 40 percent of people with psoriatic arthritis who take leflunomide will have improvement in their joints. B-cell inhibitors Belimumab (Benlysta) and rituximab (Rituxan) target proteins on the surface of B cells (a type of white blood cell involved in inflammation). Doctors typically won’t use this therapy until other treatments for psoriatic arthritis prove ineffective, according to the Arthritis Foundation. Cyclosporine Approved by the U.S. Food and Drug Administration (FDA) for treating psoriasis, cyclosporine may also help relieve some psoriatic arthritis symptoms, research suggests. “But the studies are small, and it’s not FDA-approved for the treatment of psoriatic arthritis,” says Dr. Buckley. She points out that physicians typically use cyclosporine as an add-on therapy with other medication to get additional benefits. There may be additional adverse reactions that are specific to each type of medication; the list of drugs below provides a brief, non-exhaustive list of potential side effects. TFN inhibitors Injectable drugs, including injectable TFN inhibitors, can often lead to skin reactions or allergic reactions, such as a rash that can itch or burn, according to the American College of Rheumatology. Interlukin inhibitors Ixekizumab can have potential side effects that include diarrhea and nausea. Secukinumab and ustekinumab can cause headache and fatigue as well as allergic or injection-site reactions. JAK inhibitors Side effects of JAK inhibitors can include nausea, indigestion, diarrhea, headaches, upper respiratory tract infections, and increased cholesterol levels, according to CreakyJoints, a not-for-profit advocacy organization for people with arthritis. In rare cases these medications can cause more serious issues such as infection. Methotrexate When methotrexate is used in small doses, as is usual for psoriatic arthritis, patients generally tolerate it well. Common side effects of methotrexate for psoriatic arthritis include nausea and mouth sores, while use of the drug raises the risk of liver damage, according to the Arthritis Foundation. Leflunomide The most common adverse reaction to leflunomide is diarrhea. Other potential side effects include hair loss, upset stomach, and liver problems. B-cell inhibitors Abdominal pain, chills, fever, and headache are potential side effects of B-cell inhibitors. Cyclosporine Side effects of cyclosporine include kidney damage, high blood pressure, and high cholesterol. If you take cyclosporine, your doctor will give you regular blood tests to check your kidney function. TNF inhibitors People who have been diagnosed with multiple sclerosis or who have significant heart failure should not take a TNF inhibitor, according to the American College of Rheumatology. Interleukin inhibitors If you’ve been diagnosed and treated (presently or in the past) for cancer, diabetes, a heart condition, or a nervous disorder, you may be at increased risk for an adverse event caused by interleukin inhibitors. Discuss the risks and potential alternatives with your healthcare provider. JAK inhibitors Medications that treat certain chronic conditions such as chronic respiratory conditions, diabetes, heart disease, and stroke may interact with a JAK inhibitor, so it’s important to discuss any other medications you are taking with your doctor. Methotrexate Because of the potential for liver damage when taking methotrexate, people with alcoholism or impaired liver function, such as those with cirrhosis or hepatitis, should not take this drug. Pregnant or nursing women and women (and their male partners) who are planning for pregnancy shouldn’t take this medication, either. People with active peptic ulcers, kidney abnormalities, and preexisting blood problems should also avoid methotrexate. Leflunomide People who have impaired liver function or alcoholism should not take leflunomide. Since it can cause serious birth defects, women who are pregnant should avoid taking it, too. And as it can take years for leflunomide to get out of your system, both men and women who are planning to have a child should talk to their doctors. B-cell inhibitors For individuals who have had hepatitis B, the B-cell inhibitor rituximab has sometimes caused the virus to reactivate; before beginning therapy, you should be tested for the infection. Cyclosporine People who have abnormal kidney function, uncontrollable high blood pressure, a history of cancer, or severe gout should not take cyclosporine. Women who are breastfeeding and people who are undergoing radiation treatment should also avoid this medication.
COVID-19 and Immunosuppressant Drugs
Although researchers are still learning about how COVID-19 impacts people with psoriatic arthritis and other autoimmune diseases, so far, the evidence is encouraging. A panel of experts from 17 research institutions and the National Psoriasis Foundation did not find scientific evidence to suggest that medical interventions for people with psoriatic arthritis or psoriasis should be changed; the guidelines released by the group recommend that people with either condition continue their normal treatment during the COVID-19 pandemic. According to a study from John Hopkins University Bloomberg School of Public Health in Baltimore published in January 2021 in Clinical Infectious Diseases, people on immunosuppressive drugs did not, on average, have worse COVID-19 outcomes, including longer length of stay in the hospital, death in hospital, or use of a ventilator compared with people who were not immunosuppressed. The authors wrote, “Our results contribute to a growing body of evidence that should provide reassurance to clinicians and patients using chronic immunosuppressive medicines.”
5 Questions for Your Doctor
When discussing immunosuppressant drugs to treat psoriatic arthritis, ask your doctor the following:
What results should I expect while on this medication?How quickly should I expect to see results?How will you monitor my response to this medication?What side effects should I watch out for while I’m taking this medication?What is my next treatment option if this medication doesn’t work?
