Female psoriatic arthritis patients respond differently to biologic treatment. Here's what to know to optimize their care

Psoriatic arthritis (PsA) is an inflammatory, immune-mediated disease that can wreak long-term havoc on patients’ joints and skin. While the disease occurs equally in men and women, biological sex influences disease manifestations and even treatment responses.^[]

“Psoriatic arthritis in men often presents with more axial involvement—the spine and sacroiliac joints—and more severe disease in these areas,” says Stella Bard, MD, a board-certified rheumatologist who manages complex rheumatologic conditions. “Women with PsA tend to have more peripheral joint involvement, such as in the hands and feet. Women also report higher levels of pain, fatigue, and overall disease burden compared to men.”

What the research says

Research has shown that female patients—even those with similar disease activity and comparable levels of biological treatments as males—experienced lower quality of life, greater levels of disability, and higher work impairment, according to The Journal of Rheumatology.^[] Sex hormones like estrogen may play a role, as estrogen is pro-inflammatory and leads to the release of cytokines like TNF, IL-6, and IL-1.

Biologic disease-modifying antirheumatic drugs (bDMARDs) for PsA are frequently prescribed, as they show solid disease control and reduced radiographic disease progression. Here’s what you should know about how female patients respond to biologics. 

Sex impacts treatment response

First, biologics do work: “Biologics are effective in treating PsA in both men and women. Generally, they’re effective in reducing symptoms and preventing joint damage in both sexes,” Dr. Bard says. “[But] some studies suggest that women may experience more side effects from biologics, and that they might choose to discontinue taking them.”

An evaluation of IL-12/23 therapy with or without methotrexate found that females saw longer diagnostic delays and experienced a higher rate of methotrexate (MTX) therapy.^[] Erythrocyte sedimentation rates were also elevated in women, and changes from baseline to week 24 of treatment “were generally reduced in females versus males, but differences did not achieve statistical significance.” More so, female patients saw more gastrointestinal issues when using ustekinumab and MTX. 

Dr. Bard says that she very carefully considers when to prescribe biologics to her female PsA patients. “Women may face decisions involving reproductive health, pregnancy, and hormonal changes, which can all affect disease activity and treatment choices,” she says. “A patient’s personal and family life is none of my business, but because it plays such a critical role in choosing the right treatment, we need to address it in the beginning and readdress [it] when necessary.”

“Physicians should consider the safety of certain treatments for every stage of a woman's life, ” Dr. Bard adds. For example, Dermatologic Therapy found that IL-23 inhibitors may be associated with unexplained recurrent spontaneous abortions.^[] Aly Cohen, MD, a rheumatologist and integrative medicine practitioner, agrees. She says that she also tries to get her female PsA patients to try making key lifestyle changes before prescribing them a biologic. 

“When people have tried for 3 months to clean up their lifestyle with a good diet [and good] water quality, adding in high-quality supplements and supporting their gut microbiome,” she says, “I’ll do the blood work and x-rays, and then I can understand how aggressive and nonaggressive to be [with treatment].”