Psoriatic arthritis

Complaints in psoriatic arthritis

It differs per person how the symptoms start or how the psoriatic arthritis progresses. The symptoms can range from relatively mild to severe.
When you have skin psoriasis and psoriatic arthritis together, you have complaints due to joint inflammation and skin problems.

Psoriatic arthritis can affect any joint in the body and it may affect just one joint, several joints or multiple joints. Psoriatic arthritis typically affects the large joints (elbow or knee), the small joints (hands and feet), distal joints of the fingers and toes, the back of your back, the sacroiliac joints of the pelvis and where your ribs are attached to your chest. The inflamed joint is often stiff, so perhaps you cannot move, stand up or walk well. An inflamed joint hurts and the inflamed spot is swollen, red and warm. Affected fingers and toes can resemble swollen sausages, a condition often referred to as dactylitis. Finger and toe nails also may be affected. Psoriatic arthritis in the spine, called spondylitis, causes stiffness in the back or neck, and difficulty bending. It can also can cause tender spots where tendons and ligaments join onto bones. Inflamed tendon attachments give you a lot of pain, but there is nothing to see on the skin. This condition, called enthesitis, can result in pain at the back of the heel, the sole of the foot, around the elbows or in other areas. Enthesitis is one of the characteristic features of psoriatic arthritis.

Psoriasis is a skin disease in which scaly red and white patches develop on the skin (elbows, knees, scalp, navel, palms, soles of the feet or skin folds). It can also cause wells in the nails and brown discolouration to develop under the nail. Psoriasis is caused by the body’s immune system going into overdrive to attack the skin. Some people with psoriasis can also develop psoriatic arthritis, manifested by painful, stiff and swollen joints.

In both psoriasis and psoriatic arthritis the disease flares may alternate with periods of remission, subside, vary from person to person and even change locations in the same person over time.

What can be the complaints in psoriatic arthritis?
• pain and inflammation in the joints, including inflammation of the sternum joint or the collarbone joint. Almost all joints can become inflamed. An inflamed joint hurts and the inflamed area is swollen, red and warm. Sometimes the toe or finger joints swell spontaneously.
• stiff joints. The inflamed joint is often stiff, so you can not move, get up or walk properly.
• inflammation at the attachment points of the tendons to the bone. With inflamed tendon attachments you have a lot of pain, but there is nothing to see on the skin.
• an eye infection (uveitis or iridocyclitis).
• fatigue. Inflammation in your body not only causes pain, but also a lot of (severe) fatigue.
• skin complaints, such as red, scaling patches on the skin. Because of the psoriasis people suffer from skin problems and nail problems.
• inflammatory bowel diseases or infections (ulcerative colitis or Crohn’s disease).
• inflammation on the urinary tract.

Sometimes the symptoms of psoriatic arthritis can resemble the symptoms of rheumatoid arthritis, another form of inflammatory arthritis, but psoriatic arthritis is usually milder in the disease process.

Diagnosis

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

Anamneses
At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

To diagnose psoriatic arthritis, rheumatologists look for swollen and painful joints, certain patterns of arthritis and skin and nail changes typical of psoriasis. Some symptoms of psoriatic arthritis are also common in other conditions. It can therefore take a while before the diagnosis is made.

Physical examination
In the physical examination you will be tested for the mobility of your back and the shape of the spine. The skin and nails will be examined for skin abnormalities, especially at the hairline, navel, anal cleft and nails. If you are not already receiving treatment for psoriasis, the doctor will also see if you have red and scaling patches on your skin.The doctor will further examine whether you have inflamed joints and/or inflamed tendon attachments.

X-rays
X-rays often are taken to look for joint damage by inflammation. The X-rays are later used to assess whether your joints have improved or worsened after treatment. MRI, ultrasound or CT scans can be used to look at the joints in more detail.

Blood test
Blood tests may be done to rule out other types of arthritis that have similar signs and symptoms, including gout, osteoarthritis, and rheumatoid arthritis. In patients with psoriatic arthritis, blood tests may reveal high levels of inflammation and mild anemia but labs may also be normal. Anemia is a condition that occurs when the body lacks red blood cells or has dysfunctional red blood cells.
• Sedimentation speed. The doctor will have a blood test done to check whether the blood sedimentation in your blood has been increased by an inflammation. Blood tests also measure the degree of inflammation through the sedimentation rate of the red blood cells. The erythrocyte sedimentation rate (ESR) is measured by a laboratory test. An erythrocyte sedimentation rate (ESR) test is also called a sedimentation rate test or sed rate test. The test measures the sedimentation rate of red blood cells (erythrocytes) through the speed at which the red blood cells settle, due to gravity, in an upright, narrow tube of blood. The upper part of the blood in the tube is the plasma, which becomes visible as a column of clear, yellowish liquid after the sedimentation of the red blood cells. The length of this column of plasma is measured after one hour and expressed in millimetres per hour (mm/hour). This blood test does not diagnose one specific condition. Instead, it helps your doctor to determine whether you are experiencing an inflammation. This can be the result of infections (bacteria, viruses), tumors and autoimmune diseases (such as arthritis). You can see under a microscope whether you have many active white blood cells (T-lymphocytes) in your blood or in your skin flakes.
• Your doctor can also examine whether you have rheumatoid factors in your blood. These substances occur in people with certain forms of arthritis. People with psoriatic arthritis usually do not have rheumatoid factors in the blood. So if the doctor finds these substances in your blood tests, he will also check whether there is perhaps another form of arthritis present.

Skin biopsy
Occasionally skin biopsies (small samples of skin removed for analysis) are needed to confirm the psoriasis.

Treatment of psoriatic arthritis

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
The aim of treating with drugs is to inhibit the immune system so that the joint inflammation stops without reducing the resistance to pathogens. Treating psoriatic arthritis varies depending on the level of pain, swelling and stiffness. Those with very mild arthritis may require treatment only when their joints are painful and may stop therapy when they feel better. Good treatment can prevent further damage to the joints. The prescribed drugs ensure that you suffer less from pain and that the inflammation of the joints is slowed down. In the choice of drugs, your doctor looks at the severity of the disease, the side-effects that the drug can give and the reaction of your body to the drug. Again and again, your doctor weighs up the damage that the disease can cause to the joints and the possible side effects of a drug. How this balance goes down is different for everyone.
• An NSAID, an anti-inflammatory drug, such as naproxen (Aleve) or ibuprofen (Motrin or Advil) are used as initial treatment. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These are drugs that are effective against inflammation, pain, stiffness and fever, but do not contain corticosteroids (steroids). They do not prevent joint damage. There is no proof that any one NSAID is better than others. Your doctor will prescribe these prescription drugs with a higher dose of the active substance. High doses of short‐acting NSAIDs give the fastest relief of symptoms. Given in the correct dose and duration, these drugs give great relief for most patients. The NSAIDs may cause stomach upset, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease, impaired kidney function or the use of blood thinners.Your doctor will prescribe these prescription drugs with a higher dose of the active substance.
If the arthritis does not respond, disease modifying anti-rheumatic drugs may be prescribed.
• A synthetic DMARD (Disease-Modifying Anti Rheumatic Drug), for example sulfasalazine (Azulfidine), methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), cyclosporine (Neoral, Sandimmune, Gengraf), hydroxychloroquine (Plaquenil), azathioprine (Imuran) and leflunomide may be prescribed. A DMARD has different mechanisms of action and this drug can relieve symptoms and suppresses joint inflammations and damage to the joints. When using a DMARD at an early stage of your condition, your joints will be less damaged by the inflammations. This class of drugs is helpful mainly in those with arthritis that also affects the joints of the arms and legs.
Sometimes combinations of these drugs may be used together. Hydroxychloroquine (anti-malarial drug Plaquenil) can help, but is usually avoided as it can cause a flare of psoriasis. Azathioprine (Imuran) may help those with severe forms of psoriatic arthritis.
• A corticosteroid (an artificial adrenal cortex hormone) is a medicine that resembles the natural hormone that the body produces in the adrenal cortex. They are anti-inflammatory drugs that suppress the immune response in the body and inflammation. A corticosteroid drug can be quickly effective for a joint swelling that is localized (not widespread) by an injection or shot into the effected joint or tendon sheath (the membrane around a tendon).
• A biologic DMARD (biologic inhibitor). There are several biologic type drugs available to treat psoriatic arthritis via infusion or injection. The doctor will check first if you do not have other infections, tuberculosis, heart failure or a malignant disease. These diseases can in fact be exacerbated by treatment with a biologic and must therefore be treated first. If you are a patient with a latent tuberculosis (no symptoms) you may develop an active infection. Therefore, you and your doctor should weigh the benefits and risks when considering treatment with a biologic. Patients with arthritis in the knees, ankles, elbows, wrists, hands and feet should try a DMARD therapy before an anti-TNF treatment.
A biologic is a drug that can affect your immune system. If you are healthy, the immune system itself produces enough antibodies to defend itself against pathogens (viruses and bacteria). This balance is disrupted in people with chronic inflammatory disease. A biologic can restore that balance.
TNF alpha inhibitors (a class of drug known as biologic), that are used:
• Adalimumab (Humira), etanercept (Enbrel), golimumab (Simponi), certolizumab (Cimzia) and infliximab (Remicade) which can help treat psoriatic arthritis as well as skin psoriasis.
• Secukinumab (Cosentyx), a new type of biologic injection, was approved to treat psoriatic arthritis and can also be helpful in treating psoriasis.
• Ustekinumab (Stelara) is a biologic injection, that is effective in treating psoriatic arthritis and psoriasis.
• Abatacept is given to patients who have not responded to one or more DMARDs or other biologic drugs. Abatacept may be used alone or in combination with DMARDs.
• A biosimilar. A biosimilar drug is a drug that is developed to be highly similar and clinically equivalent to an existing biologic. A biosimilar drug contains a version of an active substance of an already approved biologic drug (the ‘reference drug’ or ‘originator drug’). Similarity to the reference biologic in terms of quality, structural characteristics, biological activity, safety and efficacy must be established, so that there are no clinically meaningful differences from the biologic in terms of quality, safety and efficacy. Research has shown that the biosimilar is just as effective as the original biologic inhibitor in the treatment of arthritis.
Biosimilar drugs are not the same as generic drugs, which contain simpler chemical structures and are identical, in terms of molecular structure, to their reference drugs.

Surgical treatment
Surgery can be helpful to repair or replace badly damaged joints, such as with osteoarthritis.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

Side-effects
• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side-effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks.

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Living with psoriatic arthritis

How much the impact of psoriatic arthritis affects your life depends on the different joints involved and the severity of symptoms. Severe fatigue and anemia are common with the disease. Sometimes patients also experience mood changes. Treating the arthritis and reducing the levels of inflammation helps with relieving the problems. Maintaining a healthy weight and treating high blood pressure and cholesterol are also important aspects of treatment.
People with psoriasis are slightly more likely to develop high blood pressure, high cholesterol, obesity or diabetes.

Many people with psoriatic arthritis can benefit from physical and occupational therapy to strengthen muscles, protect joints from further damage and increase flexibility. Stiff joints and muscle weakness are due to lack of use. Proper exercise is very important to improve overall health and keep joints flexible.
• walking is an excellent way to get exercise. A walking aid or shoe inserts will help to avoid undue stress on feet, ankles or knees affected by arthritis.
• an exercise bike is another good option if you want to exercise at home.
• yoga and stretching exercises can help with relaxation.
• exercising in water. Swimming or walking laps in the pool offers activity without too much pressure on the joints.

Patient Education Library
Psoriatic Arthritis
https://www.ypo.education/rheumatology/psoriatic-arthritis-t169/video/

Videos sources

Nature video I Psoriasis and beyond: targeting the IL-17 pathway I https://youtu.be/aYNgLQNpA6E
Patient Education Library I Psoriatic Arthritis I https://www.ypo.education/rheumatology/psoriatic-arthritis-t169/video/