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Table 1: Grade of recommendations of DMARDs in peripheral PsA MTX B A

Peripheral joint inflammation Psoriasis

Radiographic progression Dactylitis Enthesitis Toxicity

–D C C



–A –C ? ?


CsA B A C ? ?


LFN A B D ? ?


Table 2: Potential risk and contraindications of the three main DMARDs in PsA Potential risk

Haematological Liver function Renal function Hypertension Gastrointestinal

Skin disorders Infectious events

MTX ++

+++ +/– + +

++ ++

CsA + +


+++ +

+ +

MTX=methotrexate; CsA=cyclosporin A; SSZ=sulphasalazine; LFN=leflunomide

most frequent were diarrhoea, raised liver function tests, flu-syndrome and headache, and they were more common compared with the group treated with placebo.17 Recently, a large prospective observational study showed good effectiveness for LEF in a group of 514 PsA patients. The discontinuation rate was 12.3% and 93 adverse drug reactions occurred in 62 patients (12.1% of the total). The drug reaction was serious in only three cases, with an increase of liver enzymes in two and hypertensive crisis in one.18 As a general warning, alcohol and fatty foods should not be taken when this medication is prescribed.

Systemic corticosteroids Generally, systemic corticosteroids are contraindicated in patients with psoriasis.3 However, corticosteroids are often used in PsA patients, and data from the CASPAR study6

recommendations of DMARDs and the potential risk and contraindications in PsA, respectively.


Overall, the data obtained from literature are supporting the wide use of synthetic DMARDs and, to certain extent, of NSAIDs and corticosteroids for PsA. Indeed, MTX seems to be a quite common therapeutic option for the PsA with a mild tendency to induce some mild adverse effects. Similar results, in terms of side effects, are obtained by the other DMARDs.

As contraindications, alcohol intake, fatty liver, high blood pressure and kidney failure are the main factors to take into account when a treatment is planned for PsA. Finally, corticosteroids, even if they are quite common medications for PsA, should be contraindicated as potential harmful drugs for psoriasis. l

showed that they were used in 11% of the total population (n=433) as first medication. In fact, as immunosuppressive agents, corticosteroids can be effective in skin disease but their withdrawal can cause a dramatic rebound of the psoriasis with a potential generalised pustular form, the so-called Von Zumbusch psoriasis.3 The use of these medications is, therefore, contradictory, due to the different perspectives of dermatologists and rheumatologists.

8 Tables 1 and 2 summarise the grade of

References 1. Pipitone N et al. Current concepts and new developments in the treatment of psoriatic arthritis. Rheumatology (Oxford) 200;42:1138–48.

2. Wanders A et al. Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing apondylitis. A randomised clinical trial. Arthritis Rheum 2005;52:1756–65.

3. Griffiths CE. Therapy for psoriatic arthritis: sometimes a conflict for psoriasis. Brit J Rheumatol 1997;36:409–12.

4. Ingegnoli F et al. Focus on the potential effects of

SSZ ++ ++

+/– +

++ ++ ++

treatments for spondylarthritides on cardiovascular risk. Expert Rev Clin Immunol 2014;10(2):307–15.

5. Soriano E. The actual role of therapy with traditional disease-modifying antirheumatic drugs in psoriatic arthritis. J Rheumatol Suppl 2012;89:67–70.

6. Helliwell PS, Taylor WJ. Treatment of psoriatic arthritis and rheumatoid arthritis with disease modifying drugs – comparison of drugs and adverse reaction. J Rheumatol 2008;35:472–6.

7. Ricci M et al. Sopravvivenza a lungo termine del trattamento con methotrexate nell’artrite psoriasica. Reumatismo 2009;61:125–131.

8. Kingsley G et al. A randomized placebo-controlled trial of methotrexate in psoriatic arthritis. Rheumatology 2012;51:1368–77.

9. Le Boëdec M et al. Baseline laboratory test abnormalities are common in early arthritis but rarely contraindicate methotrexate: study of three cohorts (ESPOIR, VErA, and Brittany). Semin Arthritis Rheum 2013;42(5):474–81.

10. Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009;61(3):451–85.

11. Lubrano E, Soriano E, FitzGerald O. Can traditional disease-modifying anti-rheumatic drugs be withdrawn or tapered in psoriatic arthritis? Clin Exp Rheumatol 2013;31(4 Suppl. 78):S54–8.

12. Clegg DO, Reda DJ, Adbellatif M. Comparison of sulphasalazine and placebo for the treatment of axial and peripheral articular manifestations of the seronegative spondyloarthritis: a Department of Veterans Affairs Cooperative Study. Arthritis Rheum 1999;42:2325–9.

13. Spadaro A et al. Comparison of cyclosporin A and methotrexate in the treatment of psoriatic arthritis. A one year prospective study. Clin Exp Rheum 1995;13:589–93.

14. Fraser AD et al. A randomised, double blind, placebo controlled, multicentre trial of combination therapy with methotrexate plus ciclosporin in patients with active psoriatic arthritis. Ann Rheum Dis 2005;64:859–64.

15. Salvarani C et al. A comparison of cyclosporine, sulphasalazine, and symptomatic therapy in the treatment of psoriatic arthritis. J Rheumatol 2001;28:2274–82.

16. D'Angelo S et al. Combination therapy with ciclosporin and etanercept in patients with psoriatic arthritis. Ann Rheum Dis 2010;69(5): 934–35.

17. Kaltwasser JP et al. Efficacy and safety of leflunomide in the treatment of psoriatic arthritis and psoriasis:a multinational, double-blind, randomized, placebo-controlled trial. Arthritis Rheum 2004;50:1939–50.

18. Behrens F et al. Leflunomide in psoriatic arthritis: results from a large European prospective observational study. Arthritis Care Res (Hoboken) 2013;65(3):464–70.

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