Psoriatic Arthritis with Predominant Enthesitis: Next Step When NSAIDs and Local Injections Have Not Achieved Relief

Clinical scenario

This protocol applies to psoriatic arthritis presenting with unequivocal enthesitis as the predominant manifestation — definite entheseal inflammation (confirmed clinically and, where needed, by additional diagnostic imaging) — in patients who have not achieved adequate relief with initial therapy.

Previous therapy did not meet its target

Initial management with NSAIDs for musculoskeletal symptom relief and local glucocorticoid injections as adjunctive therapy aimed to achieve relief of entheseal signs and symptoms within 4 weeks. When this target is not reached, escalation to the next treatment line is indicated.

Next-line approach

For patients with unequivocal predominant enthesitis and an insufficient response to initial therapy, current evidence supports escalation to a biologic DMARD (bDMARD). Multiple approved agents across different mechanisms of action are available — the full structured protocol specifies which options apply and under what conditions.

Treatment targets

Improvement at 3 months; remission or low disease activity at 6 months, guided by regular disease activity assessment and appropriate adjustment of therapy.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1136/ard-2024-225531

In patients with unequivocal enthesitis and an insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered.

Unequivocal enthesitis refers (as in 2019) to definite entheseal inflammation (which might need additional diagnostic imaging) to avoid overtreatment of entheseal pain not related to PsA.

For unequivocal predominant enthesitis, the proposal is to introduce a bDMARD (without a preference for a specific mode of action) since all currently approved bDMARDs have demonstrated efficacy on enthesitis, with similar magnitudes of response, although head-to-head trials are missing.

Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy.

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