Case-Based Approach for the Management of Rheumatic Diseases - Episode 13
Transcript: Grace C. Wright, MD, PhD: There are lots of discussions about, “What do you do next?” She was already put on methotrexate, and I’m going to bring in the point that she’s got a young child. This is somebody who’s having children—maybe this is her first, maybe it’s her last. We need to have that discussion, because methotrexate may not be a sustainable drug for her. If she’s thinking of a pregnancy at some point in the near future, we might want to choose a therapy that allows her to be well without methotrexate as backbone therapy.
The options we have include the TNF [tumor necrosis factor] inhibitors. Many people would say let’s put her on some NSAIDs [nonsteroidal anti-inflammatory drugs]. NSAIDs over the long haul have their own layers of toxicity, and they don’t alter the disease. They’re not going to treat her psoriasis, and they’re not going to treat her erosive disease. A biologic DMARD [disease-modifying antirheumatic drug] is the place I would go, and whether we choose to use a TNF inhibitor, a self-administered TNF, or an infusion TNF. We have the IL-17s as well, which have shown to be effective in this classification. With or without methotrexate, I want to see efficacy. And in a young person, in a young woman, I also want to see efficacy. We have lots of data to guide us.
We now have coming into the market JAK inhibitors that also can be used with or without methotrexate. The field is becoming crowded from my perspective. But from her perspective it’s, “I have choice.” She gets to choose if she wants a pill, an infusion, or an injectable, and then we can take it from there. There are really lots of therapeutic options for her at this point that can address the damage in her joints and the level of physical dysfunction she feels.
First line is methotrexate. When we think about erosive damage, typically we’re going on to a biologic agent pretty rapidly, and that is where we have lots of choices. TNF inhibitors have been very effective. IL-17 inhibitors have also been very effective. So she has choices. There are other oral agents, whether it’s a PD4 inhibitor or a JAK inhibitor on the market as well. I think our staple would be between the IL-17s, the TNF inhibitors, and also the IL-23s coming in. There’s really an increasing flexibility and increasing availability of a lot of products to help manage this. But TNFs and IL-17s would be my first choice.
When we think about the totality of this patient, I think of nonsteroidals as the Band-Aid. For somebody who has some swollen joints, it may help with feeling a little better because you’re not so swollen, not so stiff. But when I think about somebody with an eroded joint, nonsteroidals really have no benefit here. She has evidence of peripheral erosion, so this is not just somebody who says, “My spine feels stiff.” And this is mostly axial disease. She has erosive disease and joint space narrowing, so cartilage is going, and she’s only 31 [years old]. We’re thinking that if I don’t do anything to inhibit damage, by the time she’s 41, she won’t be able to play with this child. So nonsteroidals really do not have a huge impact on this disease.
In addition, when we look at other agents, like flutamide and sulfasalazine, we’ve borrowed those from rheumatoid arthritis, but they are really not terribly effective or studied as extensively in psoriatic arthritis. Again, I think we have better choices than going in than combination or triple therapy with oral agents.
Corticosteroids really should be the last thing we do, especially to a young person, because we are looking at the burden and the longevity of corticosteroids and all the potential adverse effects. We also know that corticosteroids can cause flair of the skin, and the skin is 1 of the important domains you want to control with psoriatic arthritis, so corticosteroids are not the best choice for managing this person. The truth is, yes, you may get some initial calming down of the joint swelling, but we’re doing nothing for the joint erosion as well.
Transcript Edited for Clarity