Psoriatic Arthritis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyPsoriatic ArthritisSCE Rheumatology

A 48-year-old woman with psoriatic arthritis has inflammatory back pain, morning stiffness lasting 90 minutes and MRI-confirmed active bilateral sacroiliitis. She has no swollen or tender peripheral joints, no dactylitis or enthesitis, and only minimal skin psoriasis controlled with topical therapy. Two sequential NSAIDs at maximum tolerated dose over 8 weeks have failed to control her symptoms. Which conventional synthetic DMARD should be started to treat her axial disease?

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Correct answer: B — None; escalate to a biologic or targeted synthetic DMARD

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · C = shown as D · A = shown as E

D is correct. Conventional synthetic DMARDs have no demonstrated efficacy for axial inflammation in psoriatic arthritis or axial spondyloarthritis. UK (BSR) domain-based guidance directs that active axial disease failing two NSAIDs is escalated to a TNF inhibitor or IL-17 inhibitor, with a JAK inhibitor as an alternative. Methotrexate and leflunomide are reasonable for peripheral arthritis, and methotrexate also benefits skin disease, but this patient has isolated axial disease, so neither is indicated here. Sulfasalazine has modest effect on peripheral arthritis only; its historical use in sacroiliitis is not supported by outcome data. Hydroxychloroquine is not a PsA axial therapy and may aggravate psoriasis. The absence of peripheral, entheseal and significant skin involvement removes any other domain-based reason for a csDMARD.

Reference: Zhao SS et al. The 2025 British Society for Rheumatology guideline for the treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs, Rheumatology (Oxford) 2025 (escalation after NSAID failure; csDMARDs not recommended for axial disease): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12107049/