Is it Time to Add a Biologic to Your PsA Treatment Plan?


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There is currently no cure for psoriatic arthritis (PsA), an inflammatory type of arthritis known for causing joint and skin inflammation. But treatments are effective in improving symptoms, including joint pain and swelling. Ongoing treatment is vital to preventing the permanent joint damage PsA is known for causing.

Finding the right treatment for PsA can be difficult, especially when first-line therapies, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and traditional disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate, prove to be ineffective in managing symptoms and pain. Your healthcare provider may then suggest biologic DMARDs (biologics), such as Humira (adalimumab) and Enbrel (etanercept) if NSAIDs and traditional DMARDs aren’t helpful, stop working, cause harsh side effects, affect your health, or if you simply prefer fewer medication doses.

Biologics are the newest class of drugs used to treat PsA and a variety of other autoimmune diseases. These drugs have greatly improved the quality of life for people with PsA. They are genetically engineered to act like natural substances the immune system generally produces. Biologics won’t cure PsA but they will slow down its progress. Most biologics are given by injection, usually under the skin. Other biologics may be injected into a vein.

Types of Biologics

Tumor necrosis factor-alpha (TNF-alpha) inhibitors

  • Cimzia (certolizumab pegol)
  • Enbrel (etanercept)
  • Humira (adalimumab)
  • Remicade (infliximab)
  • Simponi (golimumab) 
  • Simponi Aria (golimumab) 

Interleukin 12 and 23 (IL-12/23) inhibiitors

  • Stelara (ustekinumab) 

Interleukin 17 (IL-17) inhibitors

  • Cosentyx (secukinumab) 
  • Taltz (ixekizumab)  
  • Siliq (brodalumab) 

T-cell inhibitors

  • Orencia (abatacept)

Interleukin 23 (IL-23) inhibitors

  • Ilumya (tildrakizumab-asmn)
  • Skyrizi (risankizumab-rzaa) 
  • Tremfya (guselkumab) 

Here are the reasons you and your healthcare provider might consider switching from traditional DMARDs to biologics for treating your moderate to severe PsA.

Side Effects

DMARDs, especially methotrexate, are known for causing side effects, including mouth sores, gastrointestinal problems, fatigue, reduced white blood cells, and abnormal liver function. Biologics, on the other hand, work selectively, which means they will cause fewer side effects.

This is not to say that biologics do not cause side effects. In fact, the most common side effects with biologic use are:

  • Injection site redness and rash
  • An increased risk for serious infections, including tuberculosis—a very serious lung infection
  • Lupus-like symptoms, including muscle and joint pain, hair loss, and fever

While rare, biologics are also associated with serious neurological disorders and complications, including multiple sclerosis (MS) and inflammation of the eye nerves. Anyone who takes biologics could undergo frequent monitoring, which includes liver enzyme and blood count testing.

Biologics are not appropriate for everyone. People with active infections and compromised immune systems should not use biologics. People with heart conditions, MS, or a family history of MS should avoid TNF inhibitor biologics—biologics that target tumor necrosis factor (TNF) proteins made by white blood cells and are responsible for promoting inflammation.

If you are taking a DMARD and the side effects are severe and harsh, it might be a good idea to talk to with your practitioner about switching over to a biologic. Your healthcare provider may recommend lowering the dose of the DMARD and adding on biologic treatment, which can help reduce side effects.

Little or No Treatment Response

Over the last 20 years, numerous biologics have emerged offering hope for people who aren’t getting relief from traditional DMARDs. Research shows that biologics are more effective than traditional DMARDs in addressing symptoms, improving function and quality of life, and reducing joint damage in people with PsA.

One 2019 study of people taking the biologic secukinumab for treating PsA found that those taking the drug had “lower discontinuation rates, higher persistence, and greater adherence” to treatment than patients receiving other therapies.

One 2014 comprehensive review looked at results from 108 studies of people with rheumatoid arthritis, another inflammatory arthritis that causes all-over body inflammation of the joints, skin, and internal organs. The studies involved people who were given biologics alone, methotrexate alone, or a combination of both. Study participants were assessed after six months of treatment. The researchers were able to conclude that biologics were effective in reducing pain and inflammation with the greatest improvement in people using a combination of both biologics and traditional DMARDs.

One 2011 study aimed to assess the safety of adalimumab or cyclosporine—two different types of biologics—as monotherapy or combination therapy in people with PsA. The researchers of that study found that combination treatment was not only safe but also effective in providing significant symptom improvement in people with PsA, especially those who previously did not get relief from methotrexate.

Researchers, clinicians, and regulatory agencies all seem to agree that combination therapy for PsA makes sense.

New Symptoms

New symptoms or an increase in flares (periods of high disease activity) could mean that your current treatment plan isn’t working. Talk to your healthcare provider about switching treatments if current symptoms get worse or if you experienced new symptoms.

New or worsening symptoms may include:

  • Back pain and stiffness
  • Pain in different joints
  • Damaged nails
  • Bowel inflammation, which includes bloody stools and frequent diarrhea
  • Swollen fingers and toes
  • Eye inflammation, pain, redness, or blurred vision
  • Severe fatigue

Your healthcare provider may also suggest biologic treatment if X-rays start to show evidence of joint damage or if an ultrasound reveals active inflammation.

Fewer Doses

Talk to you healthcare provider about your preferences and schedule as the two of you formulate a treatment plan. Some PsA treatments are available in pill form and must be taken daily. Some biologics are taken once a week, every two weeks, or once per month. Stelara (ustekinumab), an injectable biologic, needs be injected every 12 weeks after the first two doses.

If you would prefer fewer treatments, you should ask your healthcare provider about your options.

A Word From Verywell

PsA is a long-term chronic disease and your quality of life will depend on your complete treatment plan, which includes lifestyle changes and medications. If you find you are not happy with your current treatment or if you feel treatments are not helping, talk to your healthcare provider about switching medications. There are different kinds of biologics that are approved for the treatment of PsA and many more are in the pipeline, so you have and will continue to have plenty of options.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

By Lana Barhum
Lana Barhum has been a freelance medical writer since 2009. She shares advice on living well with chronic disease.