How DMARDs and Biologics Work to Treat Psoriatic Arthritis
For moderate to severe PsA, these medicines can bring relief.

Treatment for psoriatic arthritis, or PsA, differs from person to person. Someone with mild PsA may be able to relieve their joint pain with just lifestyle modifications, and by avoiding inflammatory habits that make PsA symptoms worse (such as smoking).
For moderate to severe PsA, however, a more aggressive treatment plan may be necessary. For those who qualify, disease-modifying antirheumatic drugs (DMARDs) and biologics may be appropriate.
The goal of DMARDs and biologics is to “decrease the inflammation … rather than just mask or cover up some of the symptoms,” says Bobby Buka, MD, dermatologist and assistant clinical professor at The Mount Sinai Hospital. “If we can do that and prevent some of the inflammation in the joint space … we can preserve the joint [and] keep it healthy for the long term.”
Versions of DMARDs have been around since the 1930s—when patients literally used injectable gold to treat their rheumatic diseases (and “gold therapy” is still available today, although rarely used due to its side effects). Since then, many different agents have been used to find what brings the most relief with the fewest side effects.
Today, people with PsA have a number of DMARDs to choose from that are highly effective. “They’ve got a lower side effect profile. They are very well tolerated,” says Dr. Buka.
One subcategory of DMARDs is biologics, which target specific parts of the immune system that drive inflammation. Biologics are delivered via injection, which you can do at home, or infusion, which is done by a healthcare professional. You don’t need to worry about a daily trip to the clinic: These injections or infusions are delivered as little as once every three months.
Here’s how they work: When the immune system is actively attacking something (in this case, the joint space), it releases inflammatory proteins, which lead to swelling, pain, and redness in the area. The purpose of inflammation is to make the area undesirable to the perceived “threat,” but it can also damage the healthy tissue in the area—especially if inflammation is chronic.
Biologics work by targeting those inflammatory proteins. “Like a sponge, these biologics suck those up so that they don’t create tissue destruction or joint destruction,” says Dr. Buka.
While older treatments for PsA caused many harsh side effects, biologics only have two main side effects: soreness at the injection site, and an increased risk of infections, such as the common cold (due to the suppression of the immune system).
“[Biologics] are fabulously effective. They’re really taking our treatment of psoriasis and psoriatic arthritis to new heights,” says Dr. Buka. “We can clear or nearly clear a patient with both psoriasis and psoriatic arthritis with these biologic agents.”
Dr. Buka is a section chief at Mount Sinai School of Medicine. Dr. Buka is also a diplomate of the American Board of Dermatology and the Society for Pediatric Dermatology.
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I'm Dr. Bobby Buka, Section Chief at the Mount Sinai School of Medicine,
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and also practicing here in New York City.
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Currently, we don't have a cure for psoriatic arthritis,
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but we wanna get in front of it early.
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If we can do that and prevent some of the inflammation in the joint space
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that our body does not need, we can preserve that joint.
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Keep it healthy for the long term.
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We've got two buckets for therapy for psoriasis and psoriatic arthritis.
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One is the disease control, aimed more toward symptom management,
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and the other one is in disease therapy.
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So trying to decrease the inflammation to block any destruction
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of the joint space and to block any unnecessary inflammation to the skin.
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And that's where we focus most of our efforts rather than just mask or cover up
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some of the symptoms associated with psoriatic arthritis like pain
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or the look of psoriatic disease of the skin.
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We wanna get it at its core and get it early.
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We've got older disease-modifying agents, or DMARDs,
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like cyclosporine or methotrexate.
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Those can be very effective, but they do have the rare side effect
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of liver inflammation and kidney inflammation.
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They can be harsher agents.
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Newer DMARDs, for example, our phosphodiesterase inhibitor,
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can be very helpful to prevent the production of those inflammatory mediators.
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If we can block the production of inflammation,
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well, we're not gonna have joint destruction,
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we're not gonna have inflammation in the skin,
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and they've got a lower side effect profile.
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They are very well tolerated, maybe a little bit of stomach upset,
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and they're also orally taken, they're pills.
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A separate class, which are injectables, are the biologic class.
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These are fabulously effective.
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They're really taking our treatment of psoriasis and psoriatic arthritis to new heights.
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We can clear or nearly clear a patient with both psoriasis and psoriatic arthritis
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with these biologic agents.
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They do require some pre-screening,
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and some patients are not entirely comfortable with an injection as opposed to a pill,
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but they're working beautifully.
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And they target the inflammatory mediator, or the inflammatory protein,
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after it's been produced.
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So we have the magnet, the T-cell, and an unknown antigen connecting.
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We have the release of these inflammatory proteins.
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And now like a sponge, these biologics are gonna suck those up
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so that they don't create tissue destruction or joint destruction.
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The most common potential side effect for an injectable biologic
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is soreness of the injection site.
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Number two is maybe a common cold in the course of the year.
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So my patients that are on biologics will get the sniffles
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one or two more times in a flu season than my patients not on biologic therapy.
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Time between administration of these agents has vastly increased.
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We used to give biologics twice a week.
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Now we're up to once every three months.
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Now, that's not a cure of psoriasis, we don't have a cure.
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But if I'm doing a shot for a patient once every three months,
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that's getting there, it's pretty close.
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You know, in practice, biologics have certainly become the first line
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for psoriasis and psoriatic arthritis.
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I think in the global dermalogic community, everyone's headed in that direction,
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and some people just are requiring a bit more comfort level
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with these newer agents, than we have here.
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But I think they're incredibly successful, very safe agents,
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and we use a lot of them.
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Disease-modifying antirheumatic drugs (DMARDs). Portland, OR: National Psoriasis Foundation. (Accessed on May 2, 2021 at https://www.psoriasis.org/psoriatic-arthritis/treatments/dmards.)
Major side effects of gold therapy. Waltham, MA: UpToDate, 2019. (Accessed on May 2, 2021 at https://www.uptodate.com/contents/major-side-effects-of-gold-therapy.)
Patient education: psoriatic arthritis (beyond the basics). Waltham, MA: UpToDate, 2021. (Accessed on May 2, 2021 at https://www.uptodate.com/contents/psoriatic-arthritis-beyond-the-basics.)