This article delves into whether biologics make sense for you, how they work, and how to get started.
Basics of Psoriatic Arthritis
PsA is a type of inflammatory arthritis that often affects people who already have the inflammatory skin condition psoriasis.
Psoriasis is known for causing patches of red, inflamed skin with white, silvery flakes. PsA affects up to 30% of people with psoriasis.
Joint pain, stiffness, and swelling are the main symptoms of PsA. These symptoms can affect any part of the body, including the fingers and spine, and symptoms range from mild to severe.
PsA, much like psoriasis, causes periods of flare-ups (high disease activity) and periods of remission (reduced or no symptoms).
There’s no cure for PsA. Healthcare providers focus on controlling symptoms and preventing joint damage. Without treatment, PsA can lead to permanent damage and disability.
Biologics are a type of disease-modifying anti-rheumatic drug (DMARD) designed to manage PsA symptoms and slow down PsA disease progression.
Researchers consider biologic drugs to be the most targeted therapies for treating PsA.
Traditional DMARDs, like methotrexate, suppress the entire immune system. Biologics only target parts of the immune system that are linked to PsA. This includes immune cells and inflammatory proteins such as:
T-cells Tumor necrosis factor-alpha (TNFα) Interleukins 12, 17, and 23
These cells and proteins play a significant part in the development and progression of PsA and psoriasis.
Types of Biologics for PsA
Many biologic drugs can treat PsA. Each type of biologic targets a different pathway thought to promote the disease.
Your healthcare provider will look at your overall health, lifestyle, and severity of your disease to decide which biologic might be best for you.
TNF inhibitors: Bloc TNFα, a protein that signals the body to create inflammation. People with PsA have excess TNFα in their joints and skin. Ongoing inflammation can lead to rapid skin cell growth and joint tissue damage. IL-12/23, IL-17, and IL-23 inhibitors: Target these specific cytokines that are connected to psoriatic inflammation. Leads to less pain, fewer symptoms, and a halt in disease progression. T-cell inhibitors: Block the inflammatory activity of T-cells, which are white blood cells involved in PsA.
Your healthcare provider is in the best position to tell you whether you might benefit from biologic treatment. In general, these drugs are prescribed to people with moderate to severe PsA.
They’re also prescribed when other treatments haven’t worked, or when you cannot take other treatments because of side effects or for some other reason.
What To Expect
Biologics are administered either through injection or using an IV infusion (intravenously using a needle directly into the arm).
Most biologic injections are done at home by yourself or with the help of a loved one. Infusion therapy is done at your healthcare provider’s office, a hospital, or an infusion center.
Injections
Many of the biologic drugs approved for treating psoriatic arthritis are injected subcutaneously (under the skin). Subcutaneous injections are given in areas where you can pinch the skin, i.e., the abdomen or thighs.
Injections you can give yourself at home either come as a single-use syringe or a pen-like auto-injector. There are also powdered formulas in single-use vials. But because these require exact amounts of sterile water, they are often only used in medical settings.
Each biologic comes with preparation and dosing instructions. Your provider can give you this information and walk you through the steps for injecting yourself. The drug packaging also provides step-by-step instructions.
Dosages for biologic injections will be different based on the drug you’re taking. Some are given once or twice a week, some are once every other week, and others are once a month.
If you have questions about your dosage schedule, talk to your provider or pharmacist.
Infusions
Biologic infusions used to treat PsA include Remicade and Simponi. These medications are given through an IV drip into a vein.
An infusion appointment can take two or more hours to complete. Typically, infusion treatments are done every few weeks.
When you arrive to get your infusion, the clinician will place an IV into your vein, connected to a thin tube. Once the IV is placed, the clinician will start the infusion, and the medicine will move through the thin tube into your vein.
Make sure you feel well when you show up for an infusion appointment. This is to protect yourself and others who might also be immunocompromised (having a weak immune system).
Most biologic treatments weaken your immune system. If you have an infection that is starting, having an infusion can make it worse.
After your first infusion, you will be monitored for up to an hour for any signs of an allergic reaction—swollen lips, shortness of breath, rash, etc. You’ll get information about what side effects to watch out for and who to contact about them.
Headaches are common after biologic infusions and are often caused by fluid changes in the body. Fortunately, these headaches are temporary and should resolve within a day.
The effects of a PsA biologic begin a few weeks after the initial treatment. After you have had a few infusions, you will start to see the full effects, which can last for several months.
Talk to your healthcare provider about how you can best manage symptoms until your infusion treatments take effect.
Risks and Side Effects
All treatments come with risks and benefits, and these should be weighed carefully before starting a new treatment.
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Your healthcare provider is in the best position to explain all the pros and cons of biologic therapy for PsA and which drug might be best for your unique situation.
The most common side effects of biologics used for PsA include:
Respiratory infectionInjection site reactionsFlu-like symptoms
These side effects are generally mild. More serious side effects are rare. They include:
Some types of cancer Blood disorders Lupus-like symptoms Cardiac (heart) reactions
Getting Started
It’s typical to try traditional DMARDs like methotrexate before starting on a biologic. Biologics are expensive drugs. Some insurance companies won’t cover them unless traditional therapies have failed.
To see whether your’e a candidate for biologics, your healthcare provider will do a full assessment of your health, including your medical history, a physical exam, bloodwork, and other tests.
Let them know about other medications you are taking and take any vitamins and supplements. Some medications and supplements may interact with biologics.
You should hold off on starting a biologic when you are sick, even if it is as simple as the common cold. This is because biologic therapy impairs the immune system and increases infection risk.
Some mandatory steps must be taken before you start on a biologic:
You’ll be tested for tuberculosis (TB) and hepatitis due to the increased risk of infection and reactivation. You’ll need to be brought up-to-date on vaccinations.
Once you start a biologic, you are not only at greater risk for infection, but ineligible to receive live vaccines such as varicella and MMR (measles, mumps, and rubella) due to health risks. Getting your vaccines before starting the medication allows you to get protection from certain diseases before you are no longer able to.
Once you start biologic therapy, check with your healthcare provider before getting any routine vaccines.
Talk to your provider about your risk for certain types of cancer. Some research has linked biologic drugs with an increased risk for skin cancers and lymphoma. This risk shouldn’t stop you from starting biologics, but you may need to be monitored while taking them.
Health Disparities
Access to biologic treatment for psoriatic arthritis can be impacted by your race or ethnicity.
According to a 2015 study involving urban health institutions, Black people with PsA are far less likely to be prescribed biologics than White people. In fact, 46.2% of White people got biologics, compared to 13.3% of Black people.
Researchers said that lack of access to biologic drugs led to more severe disease, greater psychological impact, and lower quality of life.
A 2013 study showed South Asian Americans with PsA are also less likely to be treated with biologics than those with European ancestry. This study also found disparities in the treatment of Black people.
Additional Considerations
Your experience on biologic drug therapy for PsA will be different than someone else’s. There will be several things to consider as you start biologic therapy and as you continue the course.
Improvement Takes Time
It may take three or more months of biologic treatment to feel less pain and have symptom improvement from PsA. However, studies have found biologics can offer mood improvements in a shorter time.
This is important because people with PsA have a higher risk for depression and a depressed mood can worsen pain perception. That means the sooner you feel better mentally and emotionally, the sooner you’ll feel better physically.
Drug Costs
Biologics are expensive. They can cost anywhere from $10,000 to $30,000 a year.
If you have insurance, your provider will work with your carrier to find a biologic that’s covered.
If you’re not insured or your insurances leaves you with a large share of the cost, look into drug manufacturers’ patient assistance programs. They can reduce costs so you can have access to the drug your healthcare provider chooses.
Managing Flares
Even on biologics, you might still experience flare-ups—periods where symptoms are worse than usual. Flare-ups are unpredictable—you might feel fine one day and the next, you are struggling to get out of bed.
If you are experiencing frequent flare-ups or short breaks between flares, you might want to talk to your healthcare provider about whether your biologic is helping or whether it is time to start a different biologic for treating PsA.
Your biologic may not always be the reason you are experiencing flare-ups. PsA is associated with triggers—disease and lifestyle patterns that trigger symptoms. This might include things like cold weather, stress, diet, smoking, and overconsumption of alcohol.
Doing what you can to avoid triggers can pay off in the form of less pain, fewer symptoms, and improved quality of life.
Prioritizing Mental Health
Prioritizing your mental health can also help. Research shows people with PsA have a higher risk for depression and anxiety. And people who struggle to cope are more likely to experience PsA flare-ups.
Do what you can to invest in your mental health and better learn to cope with the many aspects of living with PsA, including joint and skin pain and fatigue.
You should also make sure you are making healthy lifestyle choices, including:
Eating healthyStaying activeNot smokingNot overindulging in alcohol
Sticking To Your Treatment Plan
Treating PsA takes a lot of work, and it can be hard to keep up with all the aspects of your care. The Psoriasis Foundation says the main reason PsA treatments fail is that people don’t stick to them properly.
Biologic therapy comes with some challenges, including high costs, fear of side effects, not feeling better quickly enough, or the timing of treatment might be inconvenient. It is also not uncommon for people to feel wary of biologics.
But your healthcare provider has prescribed biologic drug therapy because they have determined the benefits outweigh the risks. And, fortunately, most of the newer biologics are effective and safe to use.
Stopping treatment, regardless of the reason, is never a good idea. You will likely find yourself with increased PsA symptoms and flares as soon as you stop using your biologic or other treatments. The decision to stop or reduce treatment should be made between you and your provider.
Summary
Biologic drugs for psoriatic arthritis target various components of the inflammation response. The goal is to stop inflammation, relieve symptoms, and prevent further damage. They are usually considered after first trying other treatments.
Biologics are given by infusion or injection. Side effects include impaired defense against infections.
A Word From Verywell
Most people who try biologic drugs to treat psoriatic arthritis will see improvement in their symptoms. Follow your healthcare providers’ instructions for these treatments carefully.
It is also important to go to all regular follow-up medical visits to make sure your biologic is still working. When you see your medical provider, be sure to tell them about any problems or side effects you are experiencing.
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