Psoriatic arthritis is a chronic inflammatory condition that can lead to progressive joint damage and disability. Advances in treatment have introduced several biological disease-modifying antirheumatic drugs (bDMARDs) with different mechanisms of action, including tumor necrosis factor alpha (TNF-α) inhibitors and interleukin-17 (IL-17) inhibitors. When a patient fails to respond to one bDMARD, clinicians face the challenge of choosing the best switching strategy – either cycling to another TNF-α inhibitor or swapping to an IL-17 inhibitor (or vice versa). A recent real-world study aimed to compare the effectiveness of these two common switching strategies in psoriatic arthritis patients. The findings provide valuable insights for clinicians navigating the complex landscape of psoriatic arthritis treatment. Psoriatic arthritis, Biological therapy, TNF-α inhibitors, IL-17 inhibitors
Understanding Psoriatic Arthritis and Treatment Options
Psoriatic arthritis is a chronic, inflammatory autoimmune condition that affects the joints, tendons, and entheses, often leading to progressive joint damage and functional disability. In recent years, the treatment landscape for psoriatic arthritis has significantly improved with the introduction of various biological Disease-Modifying Antirheumatic Drugs (bDMARDs) that target different mechanisms of the disease.
The first bDMARDs available were the tumor necrosis factor alpha (TNF-α) inhibitors, such as infliximab, etanercept, adalimumab, golimumab, and certolizumab pegol. Subsequently, the arrival of interleukin (IL) 17 inhibitors (secukinumab, ixekizumab, and bimekizumab), IL-12/23 inhibitors (ustekinumab), IL-23 inhibitors (guselkumab and risankizumab), and other targeted therapies has expanded the treatment options for psoriatic arthritis patients.
Comparing Cycling and Swapping Strategies
When a patient fails to respond to one bDMARD, clinicians face the decision of which treatment strategy to pursue next. The two most common approaches are:
1. Cycling: Switching from one TNF-α inhibitor to another TNF-α inhibitor.
2. Swapping: Switching from a TNF-α inhibitor to an IL-17 inhibitor (or vice versa).
While guidelines recommend TNF-α inhibitors as the first-line bDMARD treatment for psoriatic arthritis, there is limited evidence on the optimal switching strategy after the failure of an initial bDMARD. Understanding the relative effectiveness of cycling versus swapping is crucial for clinicians to make informed decisions and provide personalized care for their patients.
Exploring a Real-World Study on Switching Strategies
A recent single-center, retrospective, observational study aimed to compare the effectiveness of cycling and swapping strategies in a cohort of psoriatic arthritis patients. The study, conducted by a team of Italian researchers, included 122 patients treated with TNF-α inhibitors and/or IL-17 inhibitors between January 2016 and January 2022.
The researchers divided the patients into three subgroups based on their switching strategy:
1. Cycling Group (CG): Patients who switched from one TNF-α inhibitor to another.
2. Swap Group 1 (SG1): Patients who switched from a TNF-α inhibitor to an IL-17 inhibitor.
3. Swap Group 2 (SG2): Patients who switched from an IL-17 inhibitor to a TNF-α inhibitor.
The study evaluated the drug retention rates, which serve as a measure of treatment effectiveness, for each subgroup using Kaplan-Meier analysis. Additionally, the researchers used Cox regression models to identify factors that influenced the treatment persistence.
Key Findings and Implications
The study’s findings provide valuable insights for clinicians managing psoriatic arthritis patients:
1. Swapping from TNF-α inhibitors to IL-17 inhibitors (SG1) showed a higher retention rate compared to cycling TNF-α inhibitors (CG) and swapping from IL-17 inhibitors to TNF-α inhibitors (SG2).
2. Factors associated with longer treatment persistence included the SG1 strategy (swapping from TNF-α inhibitors to IL-17 inhibitors), younger patient age, and lower disease activity at baseline.
3. Factors associated with reduced treatment persistence were higher disease activity at baseline and the year in which the treatment was prescribed (with more recent years showing better outcomes).
These findings suggest that in real-world clinical practice, swapping from TNF-α inhibitors to IL-17 inhibitors may be a more effective strategy than cycling between different TNF-α inhibitors. This is particularly relevant for patients in the earlier lines of treatment (2nd and 3rd lines), where the advantage of the swap strategy appears to be more pronounced.
Implications and Future Directions
The results of this study contribute to the ongoing debate regarding the optimal switching strategy for psoriatic arthritis patients who have failed a previous bDMARD. While the findings are not conclusive due to the observational nature of the study and potential biases, they provide valuable insights that can inform clinical decision-making.
Clinicians should consider the potential benefits of swapping from TNF-α inhibitors to IL-17 inhibitors, especially for patients in the earlier lines of treatment. However, further research, including larger-scale, prospective studies, is needed to confirm these findings and explore the underlying mechanisms that may explain the apparent advantages of the swap strategy.
Ultimately, the choice of switching strategy should be tailored to the individual patient’s characteristics, disease severity, and treatment history, as well as the clinician’s expertise and the available treatment options. Personalized approaches that consider the patient’s unique circumstances are crucial for optimizing psoriatic arthritis management and improving patient outcomes.
Author credit: This article is based on research by Federica Lumetti, Alarico Ariani, Antonio Marchesoni, Andrea Becciolini, Dilia Giuggioli, Gilda Sandri.
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