Hi ktel. This excerpt from the article is what stuck in my mind from Dafna Gladman’s book:
‘Notably, however, no DMARDs have been proven to slow or prevent radiographic damage. Thus, the role of these agents for patients with baseline damage is of uncertain value but is often required when access to TNF inhibitors is limited.’
However the DMARDs do have a role to play for sure, e.g. in supporting biologics plus they can help considerably with symptom control. They are so widely used and relatively cheap of course too, so I guess a worldwide move towards opting for biologics straight away in moderate to severe PsA would require a seismic shift in thinking and spending. And of course the phrase used is ‘uncertain value’ as opposed to ‘no value’. I’m sure that is carefully chosen.
Given the complexity of it all I played the game from the start so as to get where I wanted to be as soon as possible. I did the DMARDs while pushing for biologics. From my own experience I know that Mtx works for me though not as much as Humira does. And I have no idea whether it prevented progression when I took it on its own, probably not as I still had swollen joints, just much less troublesome ones.
I think it’s a case of start treatment, persevere with treatment, aim for the most aggressive treatment possible. If the jury’s out re. DMARDs for Dr Gladman and co. I’m not sure what else we patients can do.
That’s why I’m so disappointed I failed mxt - after finally getting over my year long temper tantrum. From all I read on here it appeared that later in order to enhance the biologic, mxt often just did the trick.
Well yes, but if you are intolerant of MTX, it’s not a huge problem. I believe they sometimes prescribe other DMARDS as companion meds to biologics as well, and lots of people take the biologic on its own.
Chin up, Poo! The Lake District is just around the corner.
From what I understand it’s usually a requirement to take DMARDs for at least 3 months before being eligible for biologics.
I assume that means that if the DMARDs are ineffective in controlling the inflammation you the move to biologics.
However, it seems to me if you stay on the DMARDs then you are not treating the source of the disease , just the symptoms i.e. the inflammation
Obviously controlling the inflammation is very important as that leads to the joint damage and bone erosion but only the biologic can block the mechanism.
After 3 months on the DMARDs is there then an assessment of the level of inflammation to determine if biologics are required?
If the DMARDs are effective is it then deemed unnecessary to move to the biologics?
Biologics are a DMARD drug just with a different mechanism. We act like they are different. The tradidtional DMARDs are actually far more effective on peripheral disease than are the Biologics so often folks take both. Every insurance company is different but all DO require step therapy (as do most ethical medical protocols) which starts with NSAIDs move to DMARDS then to the Biologic DMARDs.This is the proper wasy to not only diagnose but treat this disease. BTW DMARD is an acronym for Disease Modifying Anti Rheumatic Drug. The three month thing is because it takes at least that long to know if a med is working. Many docs go 6 months.
If non Biologic DMARDs are effective then $40,000/year Biologics are not necessary HOWEVER in the case of PsA, that is extremley rare. There is exactly zero evidence that non biologic DMARDs are effective against axial (spinal symptoms) that being said not al axial symptoms are sourced at the spine. OFTEN they are referred from peripheral issues. Unless you first treat the peripheral and get a handle on that, some severe damage can occur (usually in the hands and feet.)
Thanks so much for this clear and detailed explanation.
So if someone has both peripheral and axial issues treatment for the peripheral joints would be prioritized .
When you say that the axial symptoms could be referred from the peripheral issues would that then mean that the traditional DMARDs could be effective in that situation?