Switching Biologics in the Treatment of Psoriatic Arthritis

Objective: Psoriatic arthritis (PsA) is a heterogeneous inflammatory disorder that requires targeted treatment based on clinical manifestations, symptom severity, comorbidities, and other factors. Moderate or severe peripheral arthritis symptoms are typically treated with disease-modifying antirheumatic drugs (DMARDs) or biologic DMARDs (bDMARDs), and early and aggressive treatment is recommended in order to prevent permanent damage. Although rheumatologists are now able to choose between several bDMARDs for PsA that have different chemical structures, pharmacokinetic properties, dosing regimens, immunogenicity, safety profiles, and mechanisms of action, there is a lack of typical patient profiles or detailed treatment algorithms that can be followed when patients require alterations in their therapeutic regimens.

Methods: PsA treatment recommendations were evaluated to identify consensus guidelines on switching between bDMARD therapies. PubMed literature searches were then conducted using the terms psoriatic arthritis, switch/switching, biologic, and TNF/tumor necrosis factor. Articles were deemed relevant if they presented data on switching between different bDMARDs in patients with PsA.

Results: Data from the clinical literature on switching bDMARD therapies in PsA are limited. Evidence suggests that response to adalimumab, etanercept, and ustekinumab is lower after previous tumor necrosis factor inhibitor (TNFi) therapy and the efficacy of infliximab is independent of previous bDMARD treatment. Trials of ustekinumab and secukinumab showed efficacy responses were greater compared with placebo in patients who failed to respond to ≥1 TNFi.

Conclusion: Switching bDMARD therapies is a recommended strategy for patients who experience treatment failure. Many factors must be considered for determining which agent to switch to including PsA disease characteristics, comorbidities, cardiometabolic risk factors, treatment history, and patient preference. Switching between TNFis can be effective for many patients, but bDMARDs with different mechanisms of action may be superior alternatives.