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Psoriatic Arthritis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyPsoriatic ArthritisSCE Rheumatology

A 44-year-old woman with psoriatic arthritis and limited plaque psoriasis has persistent, tender enthesitis at both Achilles insertions and both plantar fascia origins, confirmed clinically and on ultrasound (power Doppler signal at the entheses). There is no synovitis, dactylitis or inflammatory back pain. Symptoms remain functionally limiting despite an adequate trial of a full-dose NSAID, orthoses and a structured loading programme, and methotrexate 25 mg weekly for 6 months has been ineffective. Which is the most appropriate next drug treatment?

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Correct answer: C — Adalimumab

Adalimumab is correct. Refractory, objectively confirmed enthesitis is a treatment domain in its own right in UK BSR psoriatic arthritis guidance: after failure of NSAIDs, local/physical measures and a conventional synthetic DMARD, escalation is to a biologic or targeted synthetic DMARD, and adalimumab (a TNF inhibitor) is the only such agent offered here. IL-17 and IL-23 inhibitors and JAK inhibitors are alternative licensed options, chosen according to skin severity, uveitis, inflammatory bowel disease and comorbidity. Sulfasalazine and leflunomide are csDMARDs with efficacy largely limited to peripheral synovitis; entheses lack synovium and respond poorly, so swapping csDMARD after methotrexate failure simply delays effective therapy. Hydroxychloroquine has no established role in psoriatic arthritis and may aggravate psoriasis; colchicine is not an evidence-based treatment for psoriatic enthesitis.

Reference: Tucker L et al. Executive summary: The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford), 2022 — enthesitis/dactylitis treatment domains: https://pubmed.ncbi.nlm.nih.gov/35640653/