Empowerment Against Lyme Arthritis: A Guide to Victory

March 5, 2024

A thorough look at Lyme disease focusing on symptoms, diagnosis, and treatments, with an empathetic deep dive into Lyme arthritis

The battle against Lyme disease is a modern medical crusade, with Lyme arthritis as one of its quintessential adversaries. Understanding the intricacies of this condition, from its harbinger symptoms to the latest evidence-based treatment strategies, is crucial for both patients and medical professionals to combat and manage this insidious disease.

Lyme disease, caused by the spiral-shaped bacteria Borrelia burgdorferi and transmitted by the bite of an infected Ixodes tick, often manifests in multiple stages with distinguishing symptoms. Thus, the crux of today’s discussion centers upon recognition, diagnosis, and management, with a special focus on the rheumatic embodiment of this bacterial invasion: Lyme arthritis.

Understanding Lyme Disease: A Primer

Lyme disease begins stealthily, often with a characteristic rash called erythema migrans. It resembles a bull’s-eye, a clear central area surrounded by redness. But not everyone with Lyme disease gets or sees this rash. Fatigue, fever, chills, headache, and joint or muscle pain may follow suit. For some, this is just the onset. When Lyme disease progresses untreated, myriad complications can arise, including what is known as Lyme arthritis.

Diving Deeper into Lyme Arthritis

Lyme arthritis, a frequent late-stage manifestation of this bacterial infection, emerges as episodic bouts of swelling and pain, generally in the large joints, especially the knees. It is often overshadowed by its more serious counterparts—neurological and cardiac manifestations—but it carries a unique burden: chronic assault on the skeletal system.

The symptoms of Lyme arthritis can be severe, and they often mimic those of other diseases. The most common signs include:

Pain in one or more joints, especially the knees, ankles, elbows and wrists

Swelling in these same areas
Redness around the affected joints
Warmth over the affected area

The disease can also be confused with other conditions, such as rheumatoid arthritis or osteoarthritis.

Decoding the Diagnosis of Lyme Disease and Lyme Arthritis

The diagnosis of Lyme arthritis, much like other manifestations of Lyme disease, hinges on a synthesis of clinical, epidemiological, and diagnostic test findings. Clinically, Lyme arthritis typically presents as periodic bouts of inflammation and pain in the larger joints, predominantly affecting the knees. It is important to determine the risk of exposure to ticks in endemic areas, which forms an integral part of the epidemiological assessment.

To confirm the diagnosis, serological testing is employed. The Centers for Disease Control and Prevention (CDC) recommends a two-step process, beginning with an enzyme immunoassay (EIA) or an indirect immunofluorescence assay (IFA). If the result is positive or borderline, a Western blot test is conducted for verification. It’s important to note, however, that false positives can occur, and test results should be interpreted in context of the overall clinical picture.

Once Lyme arthritis is diagnosed, fluid from the affected joint(s) may be aspirated and tested to rule out other causes of joint inflammation and to confirm the presence of Lyme disease. It’s crucial to ensure accurate diagnosis to enable prompt and appropriate treatment.

The Clinical Practice Guidelines on Lyme Disease

Per the Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR),the approach to prevention, diagnosis, and treatment is methodical. For patients presenting with early signs without Lyme arthritis or other significant manifestations—such as fever or rash—oral antibiotics are the mainstay of therapy. The antibiotic of choice is doxycycline unless there is a contraindication. Other antibiotic choices include amoxicillin.

The Predicament and Approach to Lyme Arthritis

When Lyme disease evolves into Lyme arthritis, the treatment canon requires augmentation. The round of treatment is oral antibiotics. If this doesn’t work, a second round of oral antibiotics is recommended. If the second round doesn’t work, then intravenous antibiotics like ceftriaxone is started.

The Reinforcement Against Lyme Arthritis

Lyme arthritis, whilst potentially persistent and damaging, is generally responsive to antibiotic therapy. However, approximately 10% of patients may experience what’s termed antibiotic-refractory Lyme arthritis, a condition not relenting even after appropriate antibiotic treatment. In such scenarios, symptomatic management, including nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular steroids, or disease-modifying antirheumatic drugs (DMARDs), may be necessitated. Some of these DMARDs include hydroxychloroquine and methotrexate.

Chronic Lyme Disease Controversy and the Lyme Arthritis Link

Chronic Lyme Disease—a term that has been the subject of much controversy, in part because it is used to describe a range of non-specific symptoms that persist after treatment. Clinical guidance emphasizes a guarded approach; the evidence supports treating Lyme arthritis clearly defined by objective signs, cautioning against prolonged antibiotic use without definitive Lyme disease evidence.

Advancing Towards Precision Medicine in Lyme Arthritis

The IDSA guidelines highlight the importance of personalized management plans, accounting for the variability in individual responses and the progression stages of Lyme disease and Lyme arthritis. The ability to study the genome and identify biomarkers for diagnosis and prognosis is a captivating horizon that could revolutionize our approach, allowing treatments tailored to an individual’s molecular makeup.

Combating Misinformation and the Future of Lyme Arthritis

The prevalence of misinformation about Lyme disease makes it important to reiterate that evidence-based medicine is the foundation for medical management, including Lyme arthritis.

Future endeavors include vaccines against Lyme disease, novel diagnostics, and even disease-modifying therapies that could alter the very foundations of Lyme arthritis treatment.

The Empathy Behind Lyme Arthritis Care

For some, Lyme arthritis is a chronic condition that can be difficult to diagnose and treat. In cases where medical therapies alone are not enough, a multi-pronged approach that combines physical therapy and lifestyle modifications can help to cushion the joints from further assaults.

One must never disregard the personal odyssey of those touched by Lyme arthritis—the pain isn’t merely physical but also psychological. Patient support groups and mental health care are equally pivotal in dealing with the repercussions of chronic illness.

In Conclusion: Your Lyme Arthritis Action Plan

Fighting Lyme arthritis is daunting, yet knowledge furnishes us with the weaponry to surmount this challenge. Remain vigilant for the signs, adhere to preventive measures, and if you suspect Lyme disease or arthritis, consult healthcare professionals promptly. They are your allies, guiding you through the forests of uncertainty toward a clearing of health.

With persistence, resilience, and informed choices, the journey with Lyme arthritis is not one of indefinite suffering but of hope, recovery, and triumph over adversity.

Call to Action

Remember, your proactive steps can signify the difference between lingering symptoms and reclaiming well-being. Take the information here as your starting point and journey towards a healthier future.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis, and treatment.

References

Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis. 2021 Jan 23;72(1):1-8. doi: 10.1093/cid/ciab049. PMID: 33483734.

Diseases and Conditions

What is pseudogout?

January 1, 2019

Pseudogout? What exactly is pseudogout? We typically divide inflammatory arthritis into the following categories: degenerative arthritis (i.e., osteoarthritis), autoimmune arthritis, arthritis caused by infections (septic arthritis), arthritis caused by cancer (neoplastic and paraneoplastic arthritis), and finally crystal arthopathy.

Pseudogout is a crystal arthropathy. Another common crystal arthropathy is gout. Like gout, pseudogout is very common, occurring in about 3.4% of adults. In fact, it’s the third most common cause of inflammatory arthritis.

What is pseudogout?

Pseudogout is a specific manifestation seen in calcium pyrophosphate deposition disease (CPPD). Basically, pseudogout is when CPPD flares up.

CPPD occurs when calcium pyrophosphate dihydrate deposits in cartilage and other parts of the joints. This leads to all sorts of possible symptoms. The following are just a few:

Asymptomatic: You see it on x-ray, but you don’t feel it. This is actually quite common.
Pseudogout: The joint is red, swollen, very tender, and sometimes people can have a fever. Often confused with gout or cellulitis. The knee and the wrists are commonly affected.
Chronic CPP crystal arthritis: Typically many joints are involved. It can almost look like rheumatoid arthritis or polymyalgia rheumatica.
Pyrophosphate arthropathy: This happens when people have severe osteoarthritis and then get superimposed pseudogout flares.

CPPD can also cause big deposits of crystals around the joints and bone. It can deposit on tendons, and can also involve the spine including the odontoid process. This is the part of the cervical spine that allows us to turn our neck from right to left and vice versa.

What’s the difference between pseudogout and gout?

Simply put, gout happens when monosodium urate crystals over-accumulate. Pseudogout is caused by calcium pyrophosphate crystals. This is why uric lowering medications like allopurinol or feboxustat, don’t work for pseudogout.

Who’s gets pseudogout or CPPD?

The vast majority of cases occur in people aged 55 years and above. In fact, if it occurs in someone aged less than 55 years, we need to look for other things:

Primary hyperparathyroidism
Hemochromatosis
Hypomagnesemia (from diseases and medications)
Hypophosphatasia

Other risk factors included dialysis-dependent renal failure and history of joint trauma or meniscus surgery. There are also familial forms. These genetic forms run in families and the first signs of the disease typically occurs in the person’s 20’s or 30’s. They also tend to affect the spine more.

What are the symptoms of pseudogout?

Pseudogout is an acute form of inflammatory arthritis. Look for warmth, redness, swelling, and pain. Sometimes, the joint and the skin looks infected. Sometimes people get a fever.

Usually pseudogout affects one joint at a time. But it can move around and affect more than one joint at a time. It likes the knees and wrists. However, if someone has “a bad” shoulder, pseudogout likes to go to “distressed” joints.

What triggers pseudogout?

Stress, infection, physical trauma, or a serious medical illness like a heart attack.

There are certain medications can cause a flare particularly those than decrease magnesium levels (e.g., certain forms of chemotherapy). Other medications include those that stimulate neutrophils as well as certain forms of intraarticular hyaluronic acid injections (e.g., Synvisc).

How do you diagnose CPPD?

The problem with CPPD is that it can cause arthritis without seeing it on x-ray. This happens in about 20% of cases. Consequently, the only way to 100% confirm CPPD is to pull fluid from the joint and test it for CPP crystals. Unfortunately, sometimes this isn’t possible. This is when the art of medicine really comes into play.

If possible, the joint should always be aspirated and tested. First, to confirm the diagnosis. Second, because the joint can also be infected at the same time. This happens in about 1% of cases. You don’t want to be the 1%!

Lab tests are not too helpful. There isn’t a specific test for CPPD or pseudogout. Inflammation levels are usually high including the CRP. Also about 10% of people have a positive rheumatoid factor. This is because advancing age is a risk factor for a positive rheumatoid factor. I encourage to read the article addressing this blood test in further detail. Please follow this link for further information.

How do you treat pseudogout?

If you do nothing, people typically get better on their own within 7 to 10 days. However, this is kind of brutal. Ice packs, rest, and removing the fluid from the joint may help. But, medications are often necessary. These include:

Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen, naproxen, diclofenac, etc.
Steroid injection into the joint.
Steroid injection into the muscle
Oral steroid: typically tapered over 2 weeks.
Colchicine can help
In extreme situations we can use IL-1 blockers like anakinra or canakinumab. This is very expensive and not FDA-approved. I personally use this in rare and extreme circumstances.

The choice of treatment has to be tailored to each person’s medical conditions, allergies, medications, etc. No size fits all.

Can you prevent pseudogout flares?

Unlike gout, this is actually difficult to do. Sometimes colchicine or a very low dose of prednisone can help prevent attacks. You need to weigh the risks and benefits. Again, no size fits all.

If there is something that is predisposing someone to get flares… well address it if possible. For example, if a particular medication is decreasing your magnesium levels, see whether your doctor can replace the medication. If this is impossible, supplementing with magnesium could help. Remember to discuss this with your physician first. This is not medical advice.

Conclusion

I hope this information was helpful. If you would like to learn more about pseudogout, I invite you to follow this link.

References

Rheumatology Secrets, 3rd edition

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions

Guide to living with psoriatic arthritis: Part 1

September 26, 2017

Psoriatic arthritis is an autoimmune disease that not only affects skin, but also joints

In an earlier post I presented a guide to living with rheumatoid arthritis (RA). That’s all good if you have RA, but what if your rheumatologist diagnosed you with psoriatic arthritis? What’s psoriatic arthritis and how is it similar or dissimilar to RA? This week I’ll present to you Part 1 of a Guide to living with psoriatic arthritis. I’m going to present this as a three-part series. Part 1 will cover the basics: what is psoriatic arthritis, the cause, risks, symptoms, diagnosis, and treatment. In Part 2 I’ll cover prognosis, what to expect, diet and exercise. In Part 3, I’ll be covering the financial side of psoriatic arthritis: How to get access to medications and how to navigate the complicated world of health insurance.

What is psoriatic arthritis?

Psoriatic arthritis (PsA) is a type of autoimmune inflammatory arthritis that afflicts people who suffer from psoriasis (PsO). It’s estimated that about 26% of people who suffer from psoriasis will get psoriatic arthritis at one point during their lifetime. Typically, people develop psoriasis first and then get the arthritis. In some cases, people develop arthritis first and then get psoriasis but this is a lot less common. Psoriatic arthritis is one of the more common causes of autoimmune arthritis affecting about 2 to 3% of the population.[1]

What is psoriasis and what are the different types of psoriasis?

Psoriasis is an autoimmune disease that affects the skin. It typically involves the elbows, knees, and scalp, but you can find it in many other areas. It typically causes itchiness, burning as well as a stinging sensation. Psoriasis affects about 2% of African-Americans and affects about 3.6% of Caucasians. Usually people develop it between the ages of 15 and 35, but it can also happen in very young children and older adults as well.

There are many different types of psoriasis and they are all associated with psoriatic arthritis.

Plaque psoriasis
Guttate psoriasis
Inverse psoriasis
Pustular psoriasis
Erythrodermic psoriasis (life-threatening type of psoriasis)

Please follow this link to learn more about psoriasis.[2]

What causes psoriatic arthritis?

Like most diseases in rheumatology, we’re not sure. We do know that there’s a strong genetic and environmental part to psoriatic arthritis. Here are some genetic associations.

HLA-Cw6 is associated with severe early onset skin psoriasis
HLA-B38 and HLA-B39 are associated with psoriatic arthritis
HLA-B27 is associated with psoriatic arthritis that affects the spine.

Although genes do play a part in psoriatic arthritis, most people who have psoriatic arthritis have no genetic risk factors.

The Koebner Phenomenon

Have you ever heard of the Koebner phenomenon? This phenomenon describes a new skin lesion in an area where healthy skin was injured. For example, let’s imagine that you have psoriasis. A mosquito comes along and bites you, it itches, so you scratch. Then, about 10 days later, you notice that you’ve developed psoriasis in the area you scratched. That’s the Koebner phenomenon.[3]

Now try to imagine the Koebner phenomenon involving joints. It’s thought that about 25% of people who get psoriatic arthritis develop the condition after trauma to a joint. We call this the deep Koebner phenomenon.[4]

Ultimately, we still don’t know exactly why people develop psoriatic arthritis. Our best guess like most autoimmune diseases, is that certain people are born with a predisposition to develop both psoriasis and psoriatic arthritis. Then, something in the environment triggers the disease to “come online”.

Does everyone with psoriasis get psoriatic arthritis?

No. A recent Japanese study tried to find certain risk factors that predispose patients with psoriasis to develop psoriatic arthritis. First, they found that about 17% of people with psoriasis also had psoriatic arthritis. Second, they found that people who had psoriasis involving their nails had a higher chance of having psoriatic arthritis: 29% (PsO) versus 62% (PsA). Interestingly, they also found that people who had high uric acid levels also had a higher risk of having psoriatic arthritis 9% (PsO) versus 22% (PsA).[5]

As a side note, when uric acid levels are high, this increases the risk of gout.

How does psoriasis affect the nails?

Nail psoriasis is very common. It ranges from about 50% to 87% of people who have psoriasis. Now, nail psoriasis can present in many ways depending on the anatomic site of the psoriasis inside the nail. First, a bit of anatomy.

Nail anatomy

The nail consists of the nail fold, the nail matrix, and the nail bed. The nail fold is where the blood vessels supplying the nail come from. They can be compromised in many diseases such as scleroderma. The nail matrix is responsible for formation of the nail plate and the nail bed is responsible for attaching the nail plate firmly in place.

When psoriasis affects the nail matrix. It can cause pitting, crumbling, white spots and red spots in the lunula. When psoriasis affects the nail bed, it can cause splinter hemorrhages and splitting of the nail from the nail bed (onychyolysis).[6] Please click the following link to learn more about nail psoriasis + pics.

Please note that none of the features of nail psoriasis are exclusive to psoriasis. Other diseases can cause these, including:

Reactive arthritis
Alopecia areata
Chemical dermatitis
Pemphigus vulgaris.
Incontinentia pigmenti

How is psoriatic arthritis different from rheumatoid arthritis?

Although both psoriatic arthritis and rheumatoid arthritis are both autoimmune diseases that affect joints, they are both distinct diseases. It isn’t simply because you have psoriasis and inflammation in your joints, that you have psoriatic arthritis. Many people with psoriasis have rheumatoid arthritis. Psoriatic arthritis and rheumatoid arthritis have their own pathophysiology, epidemiology, and symptoms. Although they do share many treatment options, they also have some medications tailor-made for them.

Here some of the main clinical differences between psoriatic arthritis and rheumatoid arthritis.

	Psoriatic arthritis	Rheumatoid arthritis
Joint distribution	Asymmetrical	Symmetrical
Joint involvement	DIP, dactylitis	MCP, PIPs, wrists, and MTPs
Involvement of the spine	Common	Rare, involves the cervical spine
Labs*	RF and CCP antibody negative	RF and/or CCP antibody positive

* RF = rheumatoid factor, CCP = Cyclic citrullinated peptide antibodies

As you’ll see later on, it’s a lot more complicated that. Many people presenting with psoriatic arthritis present almost exactly like rheumatoid arthritis. Here were a few other features that favor a diagnosis of psoriatic arthritis.

Presence of nail pits
When there is inflammation of the distal interphalangeal joints (Tip of your finger) without any evidence of osteoarthritis
“Sausage digits” = dactylitis. This happens when the tendons that supply of the fingers and toes get inflamed.
Any inflammation of tendons and ligaments, such as Achilles tendinitis and plantar fasciitis.
When there is a family history of psoriasis or psoriatic arthritis, particularly in a first-degree relative. That mom, dad, kids and siblings.
The spine is involved.

What are the symptoms of psoriatic arthritis?

If you’re experiencing joint pain and you have a history of psoriasis, particularly psoriasis that involves your nails, you need to think about psoriatic arthritis. So what do I mean by joint pain? When it comes to joint pain, what I really mean is, autoimmune or more specifically, inflammatory joint pain.

Psoriatic arthritis can affect almost any joint: knuckles, wrists, toes, knees, shoulders, elbows, hips, and the spine. Mechanical joint pain is very different from inflammatory joint pain. Let me explain.

Peripheral inflammatory joint pain

Peripheral joints include all joints except those involving the spine. When there is inflammation in a peripheral joint, typically people experience pain, swelling, and stiffness, particularly in the morning that lasts at least an hour. Sometimes they do see some redness and the joints may feel hot at times. Often times, people also feel a lot more tired than usual, and they can even run low-grade fevers.

Axial inflammatory joint pain

Axial joints are those that involve the spine. Inflammation involving the back causes symptoms that are very different from your usual mechanical back pain. Here are some of the following key characteristics:

Back pain present for more than three months.
Pain improves with exercise.
Pain improves with anti-inflammatory medications like naproxen or ibuprofen.
Rest usually worsens the pain.
Back pain that wakes you up during the second half of the night.
Pain and prolonged stiffness in the morning, typically lasting more than an hour.
Alternating deep buttock pain.

Enthesitis

Enthesitis means inflammation of connective tissue that attaches to bones. These include tendons, ligaments, and bursae. Most cases of enthesitis are caused by injury or overuse. Think of a marathon runner with Achilles tendinitis or a tennis player with tennis elbow. In psoriatic arthritis, the immune system attacks these connection points. So you can have someone who leads a fairly sedentary life with Achilles tendinitis on both feet, runner’s knee, and plantar fasciitis happening all at once, for no good reason. Not a pleasant experience.

Uveitis

Uveitis is a general term that we use to describe a group of inflammatory diseases that cause inflammation in many parts of the eye: uvea, lens, retina, optic nerve, and the vitreous. Depending on where the inflammation is happening, your ophthalmologist may describe it as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis.

Uveitis is associated with many diseases including psoriasis and psoriatic arthritis. Sometimes uveitis is the first manifestation of psoriatic arthritis. This is why I’ve included this topic here, even though technically it isn’t arthritis. It’s important to know and keep in the back of your mind.[7]

Patterns of disease

Just like rheumatoid arthritis, psoriatic arthritis, can manifest in many ways. For those of you who want to get really technical, I’ve included a table describing the most common ways psoriatic arthritis presents.

Subtype	Percentage	Typical joints
*Asymmetric oligoarticular disease**	15-20%	DIP joints and PIP joints of the hands and feet. MCP joints, MTP joints, knees, hips, and ankles.^#
Predominant DIP involvement	2-5%	DIP joints
Arthritis mutilans^$	5%	DIP and PIP joints
Polyarthritis^! “rheumatoid–like”	50-60%	MCP joints, PIP joints, and wrists.
Axial involvement only (spine)	2-5%	Sacroiliac joints, vertebral
Enthesitis predominant		Tendons and ligaments[8]

* oligoarticular = 2 – 4 joints

^#DIP = distal interphalangeal joints, PIP = proximal interphalangeal joints, MCP = metacarpophalangeal joints, MTP = metatarsophalangeal joints

^$ Mutilans = severely deformed

^! Polyarthritis = 5 or more joints involved

How is psoriatic arthritis diagnosed?

We currently use the CASPAR criteria to make the diagnosis of psoriatic arthritis. You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis. Obviously, there are exceptions as the CASPAR criteria are predominantly used for research purposes.

As you can see, you don’t need to have psoriasis to get a diagnosis of psoriatic arthritis. I know this sounds counterintuitive.

CASPAR classification criteria

Evidence of psoriasis (current, past, family)
- 2 points if current
- 1 point if history of psoriasis or family history
Psoriatic nail dystrophy = 1 point
Negative rheumatoid factor = 1 point
Dactylitis = 1 point
X-ray changes = 1 point

HLA-B*27 antigen

Unlike rheumatoid arthritis, we do not have blood tests to help with the diagnosis of psoriatic arthritis. At times, your rheumatologist may order something called a HLA-B*27 test.

HLA-B*27 is a genetic test. The majority of people who have a positive HLA-B*27 are perfectly healthy. HOWEVER, having a positive HLA-B*27 can put you at increased risk of developing what we call spondyloarthritis-associated diseases. This is a family of autoimmune diseases. They include:

Ankylosing spondylitis, now called axial spondylitis
Peripheral spondyloarthritis
Reactive arthritis
Psoriasis
Psoriatic arthritis
Uveitis
Crohn’s disease
Ulcerative colitis

Not every person with psoriatic arthritis will test positive for HLA-B*27, however, those that do, have a higher risk of having axial involvement.[9] This is important to know, because it may affect the medication your rheumatologist recommends.

Is there a cure for psoriatic arthritis?

The simple answer to this question is no. Psoriatic arthritis is a chronic, lifelong disease. Although there is no cure for psoriatic arthritis, there are many medications that can help halt or slow down progression: disease modifying anti-rheumatic drugs (DMARD).

Cardiovascular disease and psoriatic arthritis

In recent years, scientists have found an association between cardiovascular disease and many autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis, psoriasis, Crohn’s disease, ulcerative colitis, and psoriatic arthritis. Basically, people who suffer from psoriatic arthritis have a higher risk of developing cardiovascular disease.[10][11] [12] Unfortunately, they also tend to have more traditional cardiovascular risk factors like high blood pressure, high cholesterol, and diabetes. [13]On the upside, effective treatment of psoriatic arthritis can decrease this risk.[14]

How is psoriatic arthritis treated?

Like rheumatoid arthritis, psoriatic arthritis is treated with disease modifying anti-rheumatic drugs (DMARDs). These medications are designed to stop or slow down the progression of psoriatic arthritis by targeting the faulty part of the immune system. Without treatment, psoriatic arthritis, can cause permanent damage to joints, tendons and ligaments leading to functional impairment and a decrease in quality of life.

Which DMARDs are used to treat psoriatic arthritis?

The following are some of the medications that doctors often use to treat psoriatic arthritis. Your doctor will recommend certain treatments based on the involved joints and organs, as well as severity, allergies, and other medical conditions you may have.

I’ve broken down the different medications into the following broad categories.

Nonsteroidal anti-inflammatory drugs

Ibuprofen
Meloxicam
Naproxen
Sulindac
Etodolac
Diclofenac
Indomethacin
Celecoxib

Conventional DMARDs

Hydroxychloroquine (Plaquenil) – caution as this medication may make psoriasis flare
Methotrexate
Leflunomide (Arava)
Sulfasalazine
Azathioprine – rarely used for psoriatic arthritis

Biologics

Tumor necrosis factor – alpha (TNF-alpha) inhibitors

Certolizumab pegol (Cimzia)
Etanercept (Enbrel)
Adalimumab (Humira)
Infliximab (Remicade)
Golimumab (Simponi)

Interleukin 12 and 23 inhibitors

Ustekinumab (Stelara)

Interleukin 17 inhibitors

Secukinumab (Cosentyx
Brodalumab (Siliq) – not FDA approved for PsA
Ixekizumab (Taltz) – not FDA approved for PsA

T cell inhibitors

Abatacept

Interleukin 23 inhibitors

Guselkumab

Phosphodiesterase 4 inhibitors

Apremilast (Otezla)

To read more about treatment for psoriatic arthritis. Please follow this link.

Biosimilars

Here in the US, we are starting to see biosimilar medications. These are medications that are sort of copied from existing biologic medications. They are NOT generic medications. The problem with biosimilars is that because of their complexity, it literally is impossible to exactly copy a biologic medication. If you want to learn more about biosimilar medications, please check this article.

Can I stop my medications if I’m feeling better?

No. Psoriatic arthritis is a life-long disease. If you’re feeling better, great! However, it’s probably your medications that are keeping you that way. If you stop your medications the psoriatic arthritis will likely come back. Psoriatic arthritis subsides spontaneously in a VERY small subset of people.

If your medication is making you feel sick, talk to your rheumatologist. They truly have your best interest at mind and they want to find the best treatment for you.

Do not stop your medications without first consulting your rheumatologist.

Next steps

Let’s recap what we’ve learned today.

Psoriatic arthritis is an inflammatory arthritis that affects about 26% of people that suffer from psoriasis and affects about 2 to 3% of the population.
We know that there is a strong genetic link and environmental component to psoriatic arthritis, but the majority of cases happen spontaneously.
People with nail psoriasis have a higher risk of getting psoriatic arthritis.
The Koebner phenomenon describes the appearance of a new skin lesion in an area where healthy skin was injured. The same thing can happen in joints. This is the deep Koebner phenomenon.
Psoriatic arthritis can present in many ways. It can cause peripheral inflammatory arthritis, axial inflammatory arthritis, enthesitis, and uveitis.
Doctors use the CASPAR criteria to help make a diagnosis of psoriatic arthritis. You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis.
There are no specific tests help make the diagnosis of psoriatic arthritis, however, people that test positive for HLA-B*27 have a higher chance of having psoriatic arthritis in their spine.
People with psoriatic arthritis have a higher risk of having cardiovascular disease but treatment can possibly decrease that risk.
Psoriatic arthritis is treated with disease modifying anti-rheumatic drugs.

In part 2 of the Guide to living with psoriatic arthritis, I’ll be covering topics such as natural treatments for nail psoriasis and psoriatic arthritis, the FODMAP diet, how to exercise, and strategies on how to reduce stress. In part 3 of the Guide to living with psoriatic arthritis, I’ll be covering the financial aspect of psoriatic arthritis most notably, health insurance coverage and the prior authorization process for expensive medications.

Stay tuned and please leave your comments below!

Please follow this link to request a rheumatology consultation.

Medical Disclaimer

References

Sick woman main areas of the human body affected by psoriasis: By ann131313 via Shutterstock

Nail anatomy by Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

[1] Rheumatology secrets, 3rd edition

[2] https://www.psoriasis.org/about-psoriasis

[3] https://www.dermnetnz.org/topics/the-koebner-phenomenon/

[4] Rheumatology secrets, 3rd edition

[5] Tsuruta N, Imaguku S, Narisawa Y. Hyperuricemia is an independent risk factor for psoriatic arthritis in psoriatic patients. J Dermatol. 2017 Jul 10. doi: 10.1111/1346-8138.13968. [Epub ahead of print]

[6] Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015 Sep-Oct;33(5 Suppl 93):S7-13.

[7] https://nei.nih.gov/health/uveitis/uveitis

[8] Rheumatology Secrets, third edition

[9] Jadon DR, et al. Axial disease in psoriatic arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017 Apr;76(4):701-707. doi: 10.1136/annrheumdis-2016-209853. Epub 2016 Dec 2.

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