Considerations for Switching Biologics in the Treatment of Psoriatic Arthritis

The disease presentation of psoriatic arthritis (PA) ranges from mild to severe and debilitating. There is no “typical” patient profile, nor is there a detailed algorithm that clinicians can follow when patients require alterations in their treatment regimens. Furthermore, PA treatment is complicated by the need to manage both skin and joint disease along with comorbid disorders.

Writing in the August 2017 issue of Seminars in Arthritis and Rheumatism, Joseph F. Merola, MD, and colleagues advise that, when a patient fails to respond or no longer responds to one biologic disease-modifying antirheumatic drug (bDMARD) due to a lack of efficacy or poor tolerability, switching to another bDMARD can be a safe and effective treatment strategy. They further conclude that bDMARDs with different mechanisms of action may be the best alternatives after treatment failure. Patient response to adalimumab, etanercept, and ustekinumab is lower after previous anti-tumor necrosis factor (anti-TNF) therapy, they conclude, while the efficacy of infliximab is independent of previous bDMARD treatment.

The researchers based their analysis on consensus guidelines on switching between bDMARD therapies and articles available on PubMed under searches using the terms “psoriatic arthritis,” “switch/switching,” “biologic,” and “TNF/tumor necrosis factor.” Articles were considered relevant to their study if they presented data on switching between different bDMARDs in patients with PA.

Despite only limited clinical data on PA treatment switching, the authors found 13 switching studies that met their criteria and allowed them to draw conclusions. In addition to these studies, they identified large-scale, randomized controlled trials of ustekinumab and secukinumab, and used the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment guidelines as the source of treatment recommendations based on the involvement of the following 6 domains: peripheral arthritis, axial disease, enthesitis, dactylitis, skin, and nail. The GRAPPA guidelines also provide considerations for treatment based on the presence of concomitant comorbidities, an important issue in PA treatment.

Safety is an important consideration when prescribing bDMARDs, including the risk of serious infections and how these agents may affect cardiovascular comorbidities, the authors said. They note that numerous cases have been reported in which anti-TNFs or ustekinumab have induced or worsened symptoms of psoriasis or PA. “In such cases, switching to another agent with a similar mechanism of action is inadvisable,” they state. They detail safety recommendations for anti-TNFs in a variety of patient situations and conditions, including in women of childbearing age.

In addition, the investigators recommend including cardiologists, dermatologists, rheumatologists, and primary care physicians in treatment consultation to provide patients with comprehensive disease management. Patient and physician preferences must also be considered with respect to dosing schedules and routes of administration, along with symptom-specific treatment to guide patient therapy preferences.

“Overall, switching bDMARD therapies in PA is a recommended strategy when patients experience treatment failure,” the authors conclude. When determining which agent to switch to, physicians should consider the patient’s unique [PA] disease characteristics, comorbidities, cardiometabolic risk factors, treatment history, and personal preferences. As bDMARDs with different mechanisms of action become available, they may establish themselves as viable, and in some cases superior, alternatives.