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Intermittent joint aches

Publish date: March 9, 2022

^Medscape

A 56-year-old man presents because of intermittent joint aches and difficulty picking up his grandchild and cleaning his home. He has a 6-year history of scalp psoriasis that he has controlled with a salicylic acid shampoo. On physical examination, he has tenderness over both elbows and in his metacarpophalangeal and proximal interphalangeal (PIP) joints on both hands. Swollen joints are noted in the proximal and distal joints of the right hand. His fingernails show uniform pitting.

Neurologic examination shows no sensory deficits or hyperesthesia. Motor examination is unremarkable, and chest and abdominal findings are unremarkable. Blood pressure is 138/90 mm Hg. Radiographic imaging shows asymmetric erosive changes with very small areas of bony proliferation in the PIP joints.There is asymmetric narrowing of the joint space in the interphalangeal joints. Laboratory findings reveal an erythrocyte sedimentation rate of 35 mm/h, negative rheumatoid factor, negative antinuclear antibody, and C-reactive protein of 7 mg/dL.

These findings are consistent with a diagnosis of psoriatic arthritis. This patient has severe psoriatic arthritis based on radiographic evidence of erosive disease.

Fundamental changes in the initial pharmacologic approach to psoriatic arthritis were made in the 2018 American College Rheumatology/National Psoriasis (ACR/NPF) guidelines for the treatment of psoriatic arthritis. Previously, methotrexate had been widely used as the first-line agent. The 2018 guidelines recommend a tumor necrosis factor (TNF) inhibitor over methotrexate and other oral small molecules (leflunomide, cyclosporine, and apremilast).

Herein is a broad summary of the guidelines:

· Treat with TNF inhibitor over oral small molecule; may consider oral small molecule with mild psoriatic arthritis and psoriasis, patient preference, and/or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with oral small molecule over IL-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis and/or psoriatic arthritis
· Treat with oral small molecule over IL-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or psoriatic arthritis, or concomitant inflammatory bowel disease
· Treat with methotrexate over nonsteroidal anti-inflammatory drugs; may consider nonsteroidals for mild psoriatic arthritis and psoriasis
· Treat with IL-17 inhibitor over IL-12/23 inhibitor; may consider IL-12/23 inhibitor in a patient with concomitant inflammatory bowel disease

Note that these recommendations are based on conditional evidence (ie, low to very low quality). In fact, in the entire guideline document, only 6% of the recommendations are strong, whereas 96% are conditional. This emphasizes the importance of evaluating each patient individually and engaging in a discussion to choose optimal therapy.

Another set of guidelines, from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), was last updated in 2015. Since then, many of the agents above have been introduced. Updated GRAPPA guidelines are expected to be released later this year.

Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.

Herbert S. Diamond, MD, has disclosed no relevant financial relationships.

	Disease-modifying antirheumatic drugs
	Tumor necrosis factor inhibitor
	Interleukin-12/23 inhibitor
	Interleukin-17 inhibitor

Intermittent joint aches

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