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Psoriatic arthritis enthesitis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathiesPsoriatic arthritis enthesitisSCE Rheumatology

A 48-year-old man with psoriatic arthritis has disabling Achilles enthesitis despite topical NSAID, physiotherapy and two trials of oral NSAIDs. He has minimal peripheral synovitis and no infection. Ultrasound shows active enthesitis with Doppler signal. What is the most appropriate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Escalate to a biologic pathway after eligibility assessment

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

Escalate to a biologic pathway after eligibility assessment is best because persistent active enthesitis despite NSAIDs and physiotherapy can warrant escalation to approved biologic therapy in PsA. B is less suitable because intratendinous steroid injection risks tendon rupture; C is less suitable because long-term antibiotics are not PsA treatment; D is less suitable because allopurinol treats gout; E is less suitable because bisphosphonates treat osteoporosis or Paget disease rather than enthesitis. Clinical pearl: enthesitis is a disease domain that may justify biologic escalation even when synovitis count is low.

Reference: BSR psoriatic arthritis biologic guideline 2022; NICE NG65