How to Cope With PsA Treatment Side Effects
Like most meds, your psoriatic arthritis prescriptions come with risks. Here’s what to know about handling them well.
If you have psoriatic arthritis (PsA), it’s promising to know that there are many different treatment options out there that can help you manage the condition. You don’t have to just grimace and push through the pain and inflammation. Medications can make a huge difference in your symptoms and even slow down the progression of the disease, preventing additional joint damage.
The downside is that some of the most-often-prescribed treatments can cause side effects. Part of PsA treatment involves weighing the pros and cons of medication and deciding what side effects are worth the trade off, says Stanford Shoor, M.D., a rheumatologist at Stanford Health Care in Palo Alto, CA.
“What are the benefits versus downsides? We all make this judgment in our own minds, and people go back and forth day-to-day and week-to-week. Some people put up with that cycle, others don’t,” Dr. Shoor says.
It’s typical to start feeling side effects somewhere within the first three to six months of using a new medication, but that can vary depending on the dosage you start with, Dr. Shoor notes. Your rheumatologist will likely start you on the lowest dose possible so they can figure out how much you need to get the benefits and keep side effects to a minimum. It’s possible that you won’t feel side effects at first, but may start to notice them if your doctor recommends upping your dose over the next few months.
Side effects can also subside over time. As a medication proves effective at controlling your PsA, you may just be more willing to put up with some of the milder side effects, too, Dr. Shoor says.
Because different PsA medications work in different ways to control the disease, they come with varying side effects. Here’s what you need to know about the most common PsA medications and their side effects, and what you can do to cope with them throughout your treatment.
The Most Likely Side-Effects Culprit: Methotrexate
Like all medication, certain classes of PsA medications come with different potential side effects. The type that tends to cause the most unwelcome side effects are conventional DMARDs, and in particular, methotrexate.
Conventional DMARDs, or disease-modifying antirheumatic drugs, are typically the first line of treatment for PsA that can’t be controlled with non-steroidal anti-inflammatory drugs (NSAIDs). Medications in this class work by suppressing your immune system to control inflammation (Remember: PsA is an autoimmune condition that triggers inflammation in the joints, ligaments, and tendons). DMARDs used to treat PsA include leflunomide, hydroxychloroquine, sulfasalazine, and the most commonly used one, methotrexate.
“Methotrexate sets itself apart as being more efficacious and having more side effects,” Dr. Shoor says. For that reason, your doctor may recommend one of the other DMARDs first. Dr. Shoor calls them “entry-level drugs,” and notes that they’re not as effective, but they’re worth trying if you have mild to moderate PsA because they might help and the side effects are minimal.
For moderate or severe PsA, your doctor may recommend starting with methotrexate. It’s known for helping improve PsA, and is a generally safe drug to take, but can come with some pretty rough side effects, like fatigue, brain fog, and nausea. It can also cause liver problems, low white blood cell or platelet count, and mouth sores. “The general picture I paint for patients is that for every 100 people who start on methotrexate, 10 to 20 of them won't want to continue taking the drug,” Dr. Shoor says. The biggest reasons they cite are nausea and fatigue.
There are some things you can try to manage the side effects of methotrexate.
Change the way you take it. Some people may find they get less nauseous if they take the drug subcutaneously (injected in the layer of fatty tissue between the skin and the muscle) versus orally, Dr. Shoor says. He has also learned from patients that splitting up the dose may help. Typically, you take methotrexate once a week. The weekly dose includes multiple pills—the exact number depends on your specific situation—and you’re supposed to take them all within 12 hours. Some patients report that spreading the pills out over a few days instead prevents them from feeling sick and still seems to help control their PsA. (Of course, you should always talk with your doctor before taking your medication differently than prescribed.)
Supplement with folic acid. According to the National Arthritis Foundation, methotrexate was originally developed as a cancer drug, and part of how it works is by blocking cancer cells’ access to folic acid, a B vitamin. That’s not how it helps PsA or other forms of arthritis, but the effect is still unfortunately present no matter what condition you take it for. Without folate, healthy cells throughout the body, and especially in the gastrointestinal tract, mouth, and hair follicles, can suffer. Taking folic acid—either an over-the-counter supplement or getting a prescription from your doctor for something called folinic acid—may decrease some of the side effects of methotrexate.
Take anti-nausea medications. If you want to keep taking methotrexate but can’t bear the nausea, ask your doctor about medications that may help combat it. Zofran (ondansetron) is an anti-nausea medication often prescribed to patients on chemotherapy and radiation. Other medications, like certain antihistamines, may help with nausea as well.
Try a mouth rinse. To help mitigate mouth sores, the Arthritis Foundation recommends rinsing with salt-water or using a special mouthwash containing lidocaine.
Other methotrexate side effects may be less bothersome, but more worrisome from a health standpoint. For example, if lab tests show the medication is throwing off your liver enzymes or reducing white blood cells or platelets (responsible for proper blood clotting), that may be a sign you need to stop taking it, says Ana-Maria Orbai, M.D., director of the psoriatic arthritis program at Johns Hopkins Arthritis Center. “If a severe side effect is attributable to medication, then it has to be discontinued for safety reasons.”
While methotrexate is somewhat infamous for its side effects, that doesn’t mean other DMARDs can’t cause side effects, too—it’s just not as likely that they’ll be strong enough to disrupt your life.
Other Potential PsA Medication Side Effects
Of course, conventional DMARDs are far from the only PsA treatment out there. Biologics are a specific type of DMARDs that are made from whole cells, enzymes, antibodies, and other natural elements. While conventional DMARDs are usually taken in pill form, biologics are administered via injections or intravenous (IV) infusions. They do a similar thing—temper the immune system to reduce systemic inflammation—but each biologic works by targeting a very specific part of the immune system.
The main types of biologics for PsA are:
TNF-alpha inhibitors, which work by suppressing the body’s response to tumor necrosis factor (TNF), a protein produced by white blood cells. Examples: Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab pegol), and Simponi (golimumab)
T-cell inhibitors, which work by blocking T-cells, white blood cells that activate during the immune response to tell your body that it’s time to fight an invader. Example: Orencia (abatacept)
IL-17 (interleukin-17), IL-12/23, and IL-23 inhibitors, which work by blocking IL-17, IL-12, and IL-23, proteins that drive psoriatic inflammation. Examples: IL-17 inhibitors Cosentyx (secukinumab), Taltz (ixekizumab); IL-12/23 inhibitor Stelara (ustekinumab); and Tremfya (guselkumab)
There are also a few new oral biologics:
Otezla (apremilast) works by inhibiting phosphodiesterase 4 (PDE4), an enzyme responsible for controlling inflammatory actions within the body’s cells.
Xeljanz and Xeljanz XR (tofacitinib), work by inhibiting Janus kinases, a family of enzymes involved in immune system signaling. They’re also known as JAK-inhibitors.
The side effects of biologics are more insidious, Dr. Orbai says. They don’t tend to cause the life-interrupting fatigue, brain fog, or nausea that conventional DMARDs do—though many can cause some upset stomach, nausea, and headaches. Overall, patients usually don’t feel very sick from biologics, Dr. Shoor says.
The most common side effect is an increased risk of infection, including upper respiratory, skin, and vaginal infections. Some biologics are also associated with an increased risk of tuberculosis, non-melanoma skin cancer, and hepatitis. Otezla is also associated with an increased risk of depression and weight loss, Dr. Orbai says.
Throughout your PsA treatment, your rheumatologist will monitor you via regular blood work and physical exams to make sure you’re not experiencing any potentially dangerous side effects.
While there’s not necessarily an easy way to mitigate these side effects (beyond adopting healthy lifestyle habits to bolster health overall) your doctor will take your whole health into consideration when choosing a treatment to make sure you’re not taking something that is riskier for people with certain other health conditions. Then, it’s all about monitoring and making sure that your treatment is going smoothly and that you have as few side effects—both noticeable and hidden—as possible.
Despite the associated side effects, PsA treatments have come a long way and have made it possible for millions of people to live life without the condition dictating what they can and can’t do. With so many options to try, there’s definitely reason to be optimistic that you’ll find the right medication that balances effectiveness and side effects to reduce your pain and overall, significantly improve your life.
DMARDs Background: Arthritis Foundation. “DMARDS.” arthritis.org/drug-guide/dmards/dmards
Methotrexate Side Effects: Arthritis Foundation. (n.d.) “Methotrexate: Managing Side Effects.” arthritis.org/health-wellness/treatment/treatment-plan/disease-management/methotrexate-managing-side-effects
TNF-inhibitors: American College of Rheumatology. “Tumor Necrosis Factor (TNF) Inhibitors.” (2020.) rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/TNF-Inhibitors
Biologics: National Psoriasis Foundation. (2019.) "Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs." psoriasis.org/about-psoriasis/treatments/biologics
Oral Treatments: National Psoriasis Foundation. (2019.) "New Oral Treatments." psoriasis.org/about-psoriasis/treatments/oral-treatments