Oral treatment options for AS and PsA: DMARDs and small-molecule inhibitors

Spondyloarthritis (SpA) represents a group of common diseases that share a number of characteristic clinical manifestations including peripheral arthritis, spondylitis, enthesitis, and dactylitis. Additionally, they can often be associated with extra-articular manifestations including psoriasis, anterior uveitis, and inflammatory bowel disease. The two most widely studied clinical phenotypes are ankylosing spondylitis and psoriatic arthritis. Although a number of biologic agents have been shown to be highly effective in treating these conditions, rheumatologists must generally initiate therapy with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) such as methotrexate and sulfasalazine. The use of these medications stems from our experience in rheumatoid arthritis, and there is a paucity of convincing clinical data supporting their use in SpA. More recently, new targeted synthetic DMARDs have become available and are a welcome addition to the management of these conditions. Through this review, we hope to highlight the evidence behind available treatment options on the various domains of these diseases including synovitis, enthesitis, dactylitis, and spondylitis. We also discuss the available evidence regarding co-medication of csDMARDs with biologic agents.