How to Achieve Remission in Psoriatic Arthritis
Learn how to get psoriatic arthritis under control and keep it that way
Getting psoriatic arthritis (PsA) under control and achieving remission is possible with currently available medications. Up to 60 percent of patients with PsA compared to 44 percent of patients with rheumatoid arthritis are able to achieve minimal disease activity at one year of treatment with biologics, according to a study published in 2010 in Arthritis Research & Therapy.
Psoriatic arthritis is a form of inflammatory arthritis that affects both skin and joints. It is treated with disease-modifying antirheumatic drugs (DMARDs) and biologic drugs. In some cases, these drugs can lead to a near disappearance of symptoms, prompting patients to wonder if they still need their medication. But remission does not equal cure.
How Can I Reach Remission?
Some people may have a very mild form of PsA and get it under control relatively quickly, whereas others may have very severe disease and have to try several medications and combinations of medications to find relief. There are no clear criteria for defining remission in PsA, so it is difficult to say when you have gotten there. In general, rheumatologists talk about getting to “a minimal disease activity state.”
One of the best ways to help achieve low disease activity is through close collaboration with your rheumatologist.
“After a patient starts on a medication, we follow the patient closely, especially in the initial period. We re-evaluate their symptoms, examine their laboratory findings and then make adjustments to the medication accordingly,” says Soumya Reddy, MD, assistant professor of medicine at New York University Langone Medical Center and co-director of its Psoriasis and Psoriatic Arthritis Center. “So if a patient is not responding adequately, you have an opportunity to change or increase the dose of their medication.”
The standard of care in psoriatic arthritis is moving toward a treat-to-target (T2T) strategy. Treat-to-target is any strategy where you have a pre-specified management approach to achieve a target outcome.
“It’s typically a target that patients and physicians feel is meaningful and something that patients would be satisfied to attain,” explains Dr. Reddy. “In T2T, doctors may see patients every 4 weeks with a very clear guideline about how to escalate treatment and change therapy if the patient has not yet reached minimal disease activity. In a ‘usual treatment’ protocol, patients are seen less often, maybe every 12 weeks, and the change in treatment happens based on the preference of the patient and physician at that time. This leads to a slower escalation of therapy compared to T2T strategy, and thus potentially slower achievement of low disease activity.”
Can I Stop My PsA Medication When I Feel Better?
Once you reach a state of low disease activity, rheumatologists recommend you continue on your medications. If you take more than one medication or if your medication comes in different doses, your doctor can try taking you off of one medication, or lowering the dosage.
“I generally don’t recommend treatment discontinuation for my patients,” says Dr. Reddy. “It’s a common question and a question that many patients are interested in. But in my experience, most patients will have a recurrence or a flare within a few months of discontinuing medication. For some patients that can be as early as two weeks, but sometimes it can be as late as six months to a year. If patients wish to try discontinuing the medications after being in a minimal disease activity state for a prolonged period of time, we work with them and follow them closely during this period. The key is to get them back on medication as soon as they start getting a recurrence.”
According to a small study published online in 2013 in the journal BMJ, about 75 percent of patients had a recurrence within six months of stopping medication and most of them flared within the first two to three months. It appears that though the disease may quiet down during remission, it doesn’t cease to exist.
“I think that that’s what patients should be aware of before they embark on the trial of discontinuation of drugs,” notes Dr. Reddy. “Although there are some patients that I see who are able to discontinue medication and go into prolonged periods of remission, it’s not the common scenario,” she cautions.
Patients who have more consistent, longer duration of disease and patients who have more severe disease are at the highest risk of recurrence. Another risk factor is male gender and evidence of some clinical inflammation on ultrasound.
Can Early Aggressive Treatment Help Achieve Remission?
Starting treatment for psoriatic arthritis as early as possible could, in theory, make lasting remission more likely. Patients with psoriatic arthritis can develop significant damage early in their disease. Unfortunately, many people with psoriasis are unaware they also have PsA, and many patients are undertreated. By treating early, joint damage can be prevented, leading to improved long-term outcomes.
“A patient with PsA for 10 years may have already accumulated some amount of joint damage and possibly deformities limiting the function of their joints. So if you treat them at that point, they may still see significant improvement from treatment, but damage to the joints that has already occurred cannot be reversed,” explains Dr. Reddy.
Although some PsA patients may be frustrated by the need to stay on medication, remission is far better than no remission. One thing to remember is that while these medications work, they don’t cure the disease. “Patients sometimes ask, ‘I’m feeling great, I don’t have any psoriasis, I don’t have any joint pain, can I just stop my medication?’ Because they feel that they are cured. And that’s a testament to the highly effective medications we have these days,” says Dr. Reddy. “Sometimes after four years, you forget how you felt before, how affected your joints and your skin were prior to being on the medications.”