Early Treatment with Addition of Low Dose Prednisolone to Methotrexate Improves Therapeutic Outcome in Severe Psoriatic Arthritis
This 18-year-old HIV-negative man presented with progressively increasing low back pain, and painful red swelling and morning stiffness of the left knee, ankle, right shoulder, and multiple interphalangeal (fingers/toes) joints, and psoriasis lesions over trunk, limbs, and scalp (BSA < 20%) for the last 4 months. Nails showed Beau's lines, distal onycholysis, and loss of a few nails. All movements of the involved joints were painful and severely restricted and he was unable to walk without support/wheel chair. Except for bilateral anterior uveitis, systemic examination was normal. He had low hemoglobin (Hb 7.8 g%) and elevated erythrocyte sedimentation rate (ESR 68 mm in the first hour, Westergren method). Blood counts, serum biochemistry, rheumatoid factor, urinalysis, and X-ray chest were normal. X-rays of knees, ankles, elbows, and wrists showed periarticular soft tissue swelling and decreased joint space without significant structural damage. X-ray sacroiliac joints showed reduced joint space and sclerosis, more so of the right joint. Treatment was started with diclofenac sodium (50 mg three times daily), and hematinics and methotrexate (15 mg/week). Uveitis improved after treatment from ophthalmologist with topical atropine sulfate 1% ointment every 8 h initially and then at bed time, and prednisolone acetate 1% ophthalmic drops instilled at 1 h interval and tapered off to three times a day. Addition of indomethacin (25 mg three times/day) a week later too did not benefit and his joint pains/stiffness progressed relentlessly during the next 4 weeks when prednisolone (10 mg on alternate days) was added. Diclofenac sodium could be discontinued within a week as his joint pains and general condition improved significantly. Indomethacin was stopped and the doses were reduced for methotrexate (10 mg/week) and prednisolone (5 mg on alternate days) at 4 weeks. Subsequently, the doses of methotrexate and prednisolone were gradually tapered every 8 weeks. He is asymptomatic, participating in school sports/activities, has occasional skin lesions, uveitis resolved, hemoglobin at 10 g%, no joint deformities, or drug adverse effects during 15 months of follow-up. He is taking prednisolone (2.5 mg on alternate days) along with methotrexate 2.5 mg/week at last visit.