Psoriatic Arthritis

People beginning treatment with the immunosuppressive drugs tocilizumab (Actemra) or tofacitinib (Xeljanz) are infrequently screened for hepatitis B virus (HBV) infection, according to a new study of patients with rheumatic diseases who are starting one of the two treatments.

“Perhaps not unexpectedly, these screening patterns conform more with recommendations from the American College of Rheumatology, which do not explicitly stipulate universal HBV screening,” wrote lead author Amir M. Mohareb, MD, of Massachusetts General Hospital in Boston. The study was published in The Journal of Rheumatology.

To determine the frequency of HBV screening among this specific population, the researchers conducted a retrospective, cross-sectional study of patients 18 years or older within the Mass General Brigham health system in the Boston area who initiated either of the two drugs before Dec. 31, 2018. Tocilizumab was approved by the Food and Drug Administration on Jan. 11, 2010, and tofacitinib was approved on Nov. 6, 2012.

The final study population included 678 patients on tocilizumab and 391 patients on tofacitinib. The mean age of the patients in each group was 61 years for tocilizumab and 60 years for tofacitinib. A large majority were female (78% of the tocilizumab group, 88% of the tofacitinib group) and 84% of patients in both groups were white. Their primary diagnosis was rheumatoid arthritis (53% of the tocilizumab group, 77% of the tofacitinib group), and most of them – 57% of patients on tocilizumab and 72% of patients on tofacitinib – had a history of being on both conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs).

HBV screening patterns were classified into three categories: complete (all three of the HBV surface antigen [HBsAg], total core antibody [anti-HBcAb], and surface antibody [HBsAb] tests); partial (any one to two tests); and none. Of the 678 patients on tocilizumab, 194 (29%) underwent complete screening, 307 (45%) underwent partial screening, and 177 (26%) had no screening. Of the 391 patients on tofacitinib, 94 (24%) underwent complete screening, 195 (50%) underwent partial screening, and 102 (26%) had none.

Inappropriate testing – defined as either HBV e-antigen (HBeAg), anti-HBcAb IgM, or HBV DNA without a positive HBsAg or total anti-HBcAb – occurred in 22% of patients on tocilizumab and 23% of patients on tofacitinib. After multivariable analysis, the authors found that Whites were less likely to undergo complete screening (odds ratio, 0.74; 95% confidence interval, 0.57-0.95) compared to non-Whites. Previous use of immunosuppressive agents such as conventional synthetic DMARDs (OR, 1.05; 95% CI, 0.72-1.55) and biologic DMARDs with or without prior csDMARDs (OR, 0.73; 95% CI, 0.48-1.12) was not associated with a likelihood of complete appropriate screening.

“These data add to the evidence indicating that clinicians are not completing pretreatment screening for latent infections prior to patients starting high-risk immunosuppressant drugs,” Gabriela Schmajuk, MD, of the University of California, San Francisco, said in an interview. “It can be dangerous, since a fraction of these patients may reactivate latent infections with HBV that can result in liver failure or death.

“On the bright side,” she added, “we have antivirals that can be given as prophylaxis against reactivation of latent HBV if patients do test positive.”

Dr. Schmajuk was previously the senior author of a similar study from the 2019 American College of Rheumatology annual meeting that found only a small percentage of patients who were new users of biologics or new synthetic DMARDs were screened for HBV or hepatitis C virus.

When asked if anything in the study stood out, she acknowledged being “somewhat surprised that patients with prior immunosuppression did not have higher rates of screening. One might expect that since those patients had more opportunities for screening – since they started new medications more times – they would have higher rates, but this did not appear to be the case.”

As a message to rheumatologists who may be starting their patients on any biologic or new synthetic DMARD, she reinforced that “we need universal HBV screening for patients starting these medications. Many clinicians are used to ordering a hepatitis B surface antigen test, but one key message is that we also need to be ordering hepatitis B core antibody tests. Patients with a positive core antibody are still at risk for reactivation.”

The authors noted their study’s limitations, including the data being retrospectively collected and some of the subjects potentially being screened in laboratories outside of the Mass General Brigham health system. In addition, they stated that their findings “may not be generalizable to nonrheumatologic settings or other immunomodulators,” although they added that studies of other patient populations have also uncovered “similarly low HBV screening frequencies.”

Several of the authors reported being supported by institutes within the National Institutes of Health. Beyond that, they declared no potential conflicts of interest.

People beginning treatment with the immunosuppressive drugs tocilizumab (Actemra) or tofacitinib (Xeljanz) are infrequently screened for hepatitis B virus (HBV) infection, according to a new study of patients with rheumatic diseases who are starting one of the two treatments.

“Perhaps not unexpectedly, these screening patterns conform more with recommendations from the American College of Rheumatology, which do not explicitly stipulate universal HBV screening,” wrote lead author Amir M. Mohareb, MD, of Massachusetts General Hospital in Boston. The study was published in The Journal of Rheumatology.

To determine the frequency of HBV screening among this specific population, the researchers conducted a retrospective, cross-sectional study of patients 18 years or older within the Mass General Brigham health system in the Boston area who initiated either of the two drugs before Dec. 31, 2018. Tocilizumab was approved by the Food and Drug Administration on Jan. 11, 2010, and tofacitinib was approved on Nov. 6, 2012.

The final study population included 678 patients on tocilizumab and 391 patients on tofacitinib. The mean age of the patients in each group was 61 years for tocilizumab and 60 years for tofacitinib. A large majority were female (78% of the tocilizumab group, 88% of the tofacitinib group) and 84% of patients in both groups were white. Their primary diagnosis was rheumatoid arthritis (53% of the tocilizumab group, 77% of the tofacitinib group), and most of them – 57% of patients on tocilizumab and 72% of patients on tofacitinib – had a history of being on both conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs).

HBV screening patterns were classified into three categories: complete (all three of the HBV surface antigen [HBsAg], total core antibody [anti-HBcAb], and surface antibody [HBsAb] tests); partial (any one to two tests); and none. Of the 678 patients on tocilizumab, 194 (29%) underwent complete screening, 307 (45%) underwent partial screening, and 177 (26%) had no screening. Of the 391 patients on tofacitinib, 94 (24%) underwent complete screening, 195 (50%) underwent partial screening, and 102 (26%) had none.

Inappropriate testing – defined as either HBV e-antigen (HBeAg), anti-HBcAb IgM, or HBV DNA without a positive HBsAg or total anti-HBcAb – occurred in 22% of patients on tocilizumab and 23% of patients on tofacitinib. After multivariable analysis, the authors found that Whites were less likely to undergo complete screening (odds ratio, 0.74; 95% confidence interval, 0.57-0.95) compared to non-Whites. Previous use of immunosuppressive agents such as conventional synthetic DMARDs (OR, 1.05; 95% CI, 0.72-1.55) and biologic DMARDs with or without prior csDMARDs (OR, 0.73; 95% CI, 0.48-1.12) was not associated with a likelihood of complete appropriate screening.

“These data add to the evidence indicating that clinicians are not completing pretreatment screening for latent infections prior to patients starting high-risk immunosuppressant drugs,” Gabriela Schmajuk, MD, of the University of California, San Francisco, said in an interview. “It can be dangerous, since a fraction of these patients may reactivate latent infections with HBV that can result in liver failure or death.

“On the bright side,” she added, “we have antivirals that can be given as prophylaxis against reactivation of latent HBV if patients do test positive.”

Dr. Schmajuk was previously the senior author of a similar study from the 2019 American College of Rheumatology annual meeting that found only a small percentage of patients who were new users of biologics or new synthetic DMARDs were screened for HBV or hepatitis C virus.

When asked if anything in the study stood out, she acknowledged being “somewhat surprised that patients with prior immunosuppression did not have higher rates of screening. One might expect that since those patients had more opportunities for screening – since they started new medications more times – they would have higher rates, but this did not appear to be the case.”

As a message to rheumatologists who may be starting their patients on any biologic or new synthetic DMARD, she reinforced that “we need universal HBV screening for patients starting these medications. Many clinicians are used to ordering a hepatitis B surface antigen test, but one key message is that we also need to be ordering hepatitis B core antibody tests. Patients with a positive core antibody are still at risk for reactivation.”

The authors noted their study’s limitations, including the data being retrospectively collected and some of the subjects potentially being screened in laboratories outside of the Mass General Brigham health system. In addition, they stated that their findings “may not be generalizable to nonrheumatologic settings or other immunomodulators,” although they added that studies of other patient populations have also uncovered “similarly low HBV screening frequencies.”

Several of the authors reported being supported by institutes within the National Institutes of Health. Beyond that, they declared no potential conflicts of interest.

People beginning treatment with the immunosuppressive drugs tocilizumab (Actemra) or tofacitinib (Xeljanz) are infrequently screened for hepatitis B virus (HBV) infection, according to a new study of patients with rheumatic diseases who are starting one of the two treatments.

“Perhaps not unexpectedly, these screening patterns conform more with recommendations from the American College of Rheumatology, which do not explicitly stipulate universal HBV screening,” wrote lead author Amir M. Mohareb, MD, of Massachusetts General Hospital in Boston. The study was published in The Journal of Rheumatology.

To determine the frequency of HBV screening among this specific population, the researchers conducted a retrospective, cross-sectional study of patients 18 years or older within the Mass General Brigham health system in the Boston area who initiated either of the two drugs before Dec. 31, 2018. Tocilizumab was approved by the Food and Drug Administration on Jan. 11, 2010, and tofacitinib was approved on Nov. 6, 2012.

The final study population included 678 patients on tocilizumab and 391 patients on tofacitinib. The mean age of the patients in each group was 61 years for tocilizumab and 60 years for tofacitinib. A large majority were female (78% of the tocilizumab group, 88% of the tofacitinib group) and 84% of patients in both groups were white. Their primary diagnosis was rheumatoid arthritis (53% of the tocilizumab group, 77% of the tofacitinib group), and most of them – 57% of patients on tocilizumab and 72% of patients on tofacitinib – had a history of being on both conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs).

HBV screening patterns were classified into three categories: complete (all three of the HBV surface antigen [HBsAg], total core antibody [anti-HBcAb], and surface antibody [HBsAb] tests); partial (any one to two tests); and none. Of the 678 patients on tocilizumab, 194 (29%) underwent complete screening, 307 (45%) underwent partial screening, and 177 (26%) had no screening. Of the 391 patients on tofacitinib, 94 (24%) underwent complete screening, 195 (50%) underwent partial screening, and 102 (26%) had none.

Inappropriate testing – defined as either HBV e-antigen (HBeAg), anti-HBcAb IgM, or HBV DNA without a positive HBsAg or total anti-HBcAb – occurred in 22% of patients on tocilizumab and 23% of patients on tofacitinib. After multivariable analysis, the authors found that Whites were less likely to undergo complete screening (odds ratio, 0.74; 95% confidence interval, 0.57-0.95) compared to non-Whites. Previous use of immunosuppressive agents such as conventional synthetic DMARDs (OR, 1.05; 95% CI, 0.72-1.55) and biologic DMARDs with or without prior csDMARDs (OR, 0.73; 95% CI, 0.48-1.12) was not associated with a likelihood of complete appropriate screening.

“These data add to the evidence indicating that clinicians are not completing pretreatment screening for latent infections prior to patients starting high-risk immunosuppressant drugs,” Gabriela Schmajuk, MD, of the University of California, San Francisco, said in an interview. “It can be dangerous, since a fraction of these patients may reactivate latent infections with HBV that can result in liver failure or death.

“On the bright side,” she added, “we have antivirals that can be given as prophylaxis against reactivation of latent HBV if patients do test positive.”

Dr. Schmajuk was previously the senior author of a similar study from the 2019 American College of Rheumatology annual meeting that found only a small percentage of patients who were new users of biologics or new synthetic DMARDs were screened for HBV or hepatitis C virus.

When asked if anything in the study stood out, she acknowledged being “somewhat surprised that patients with prior immunosuppression did not have higher rates of screening. One might expect that since those patients had more opportunities for screening – since they started new medications more times – they would have higher rates, but this did not appear to be the case.”

As a message to rheumatologists who may be starting their patients on any biologic or new synthetic DMARD, she reinforced that “we need universal HBV screening for patients starting these medications. Many clinicians are used to ordering a hepatitis B surface antigen test, but one key message is that we also need to be ordering hepatitis B core antibody tests. Patients with a positive core antibody are still at risk for reactivation.”

The authors noted their study’s limitations, including the data being retrospectively collected and some of the subjects potentially being screened in laboratories outside of the Mass General Brigham health system. In addition, they stated that their findings “may not be generalizable to nonrheumatologic settings or other immunomodulators,” although they added that studies of other patient populations have also uncovered “similarly low HBV screening frequencies.”

Several of the authors reported being supported by institutes within the National Institutes of Health. Beyond that, they declared no potential conflicts of interest.

Tumor necrosis factor inhibitors have long been the go-to treatment of choice for patients with psoriasis and psoriatic arthritis (PsA). They’ve served patients well since etanercept was first approved for PsA in 2002, but today, with the availability of more attractive interleukin-17 and IL-23 inhibitors, dermatologists and rheumatologists are asking whether it’s time to reconsider the use of TNF inhibitors as first-line therapy in psoriasis and PsA.

“TNF inhibitors have served psoriasis patients well for many years. The question is, ‘Is it time to move on from them as first-line agents for psoriasis?’ ” said April W. Armstrong, MD, MPH, a dermatologist and associate dean for clinical research at the University of Southern California, Los Angeles. Dr. Armstrong participated in a point/counterpoint debate about the merits of IL-17 and IL-23 inhibitors over TNF inhibitors at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. “For the majority of our patients, IL-17 and IL-23 inhibitors are probably rationally better than TNF inhibitors as first-line agents for moderate to severe plaque psoriasis,” she said.

In this debate, dermatologists and rheumatologists cited studies showing the safety and efficacy of IL-17 and IL-23 inhibitors over TNF inhibitors. TNF inhibitors include etanercept (Enbrel and biosimilars), infliximab (Remicade and biosimilars), adalimumab (Humira and biosimilars), certolizumab pegol (Cimzia), and golimumab (Simponi). IL-12/23 inhibitors are limited to ustekinumab (Stelara). IL-17 inhibitors include secukinumab (Cosentyx), ixekizumab (Taltz), and brodalumab (Siliq). IL-23 inhibitors include guselkumab (Tremfya), tildrakizumab (Ilumya), and risankizumab (Skyrizi).

TNF inhibitors are recommended by the American College of Rheumatology as first-line therapy for treatment-naive patients with active PsA, and they, along with IL-12/23, IL-17, and IL-23 inhibitors are all recommended by the American Academy of Dermatology as monotherapy treatment options in adult patients with moderate to severe plaque psoriasis. However, some studies have shown that non–TNF-inhibitor biologics have a higher efficacy than TNF inhibitors in some cases for some patients, such as those with moderate to severe psoriasis alone or for musculoskeletal efficacy in patients with PsA who have peripheral arthritis, enthesitis, dactylitis, or axial manifestations.

Favorable characteristics of non–TNF-inhibitor biologics

Dr. Armstrong cited a number of head-to-head trials to support her view that IL-17 and IL-23 inhibitors are better than TNF inhibitors as first-line agents for patients with moderate to severe plaque psoriasis. In the first head-to-head study of its kind in patients with moderate to severe psoriasis, ustekinumab proved superior to etanercept. Guselkumab was shown to be superior to adalimumab for patients with moderate to severe psoriasis. Tildrakizumab also proved superior to etanercept for patients with psoriasis. Risankizumab bested adalimumab in patients with moderate to severe psoriasis. Ixekizumab proved superior to etanercept in two pivotal studies of patients with widespread moderate-to-severe psoriasis.

IL-23 and IL-17 inhibitors tend to have less frequent maintenance dosing, with IL-17 inhibitors being once every 2 or 4 weeks and IL-23 inhibitors once every 8 or 12 weeks, compared with frequencies ranging from every week to every 8 weeks with TNF inhibitors, Dr. Armstrong said.

IL-17 and IL-23 inhibitors also appear to have fewer safety concerns than TNF inhibitors, although there is less long-term data for them overall and there are some notable exceptions in certain patient populations. TNF inhibitors should be avoided in patients with a history of demyelinating disease or hepatitis B virus infection, and they are not preferred in patients who have a history of latent tuberculosis or advanced heart failure. IL-17 inhibitors should not be used in patients with a history of inflammatory bowel disease, and their use is associated with a higher rate of oral candidiasis. IL-23 inhibitors have a good safety profile overall, she said.

“The IL-17/23 axis is very important to psoriatic arthritis and should be the focus of our treatments” for PsA, said Deepak Jadon, MBBCh, MRCP, PhD, a rheumatologist and director of the rheumatology research unit at Addenbrooke’s Hospital, Cambridge (England) University Hospitals NHS Foundation Trust. In his presentation, he proposed that IL-17 inhibitors and IL-23 inhibitors be used as first-line therapies in PsA ahead of TNF inhibitors.

One reason to go with IL-17 and IL-23 inhibitors may be to ”get it right immunologically the first time,” Dr. Jadon said. He cited evidence showing substantially better response to guselkumab when given to biologic-naive patients with PsA versus those who had a inadequate response to TNF inhibitors, as well as data indicating better response with secukinumab regardless of previous TNF inhibitor use.

IL-17 inhibitors target more domains of psoriatic disease than do TNF inhibitors, he said, noting that “they have excellent musculoskeletal efficacy in patients with moderate skin psoriasis, not just those with severe psoriasis.” Ixekizumab proved superior to adalimumab in biologic-naive patients with PsA. The results of this study also indicated that IL-17 inhibitors should not be reserved only for patients with severe psoriasis since a higher percentage of patients with moderate psoriasis who were taking ixekizumab achieved very low PsA activity. Secukinumab also beat adalimumab in a head-to-head comparison and showed a greater impact on some measures of health-related quality of life.

IL-17 inhibitors also do not require concomitant methotrexate, he said, “which is a major bonus for our patients. All of my patients wish to stop methotrexate even if tolerated. Not having to cope with prescribed methotrexate improves risk of adverse events and frequency of blood test monitoring.”

IL-17 and IL-23 inhibitors appear to have good efficacy against axial disease in patients with PsA. Randomized trial results for secukinumab versus placebo show high percentages of patients improving either 20% or 40% in Assessment in Spondyloarthritis International Society response criteria and reduced inflammatory MRI lesions in the spine and sacroiliac joints. Analyses of trial results in guselkumab-treated patients with axial manifestations of PsA have shown the IL-23 inhibitor’s efficacy versus placebo across different measures of disease activity.

Dr. Jadon also cited real-world data showing that patients stay longer on IL-17 and IL-12/23 inhibitors versus TNF inhibitors. A 2016 study of patients with psoriasis in the PSOLAR registry showed that patients persisted on treatment longer with ustekinumab than with adalimumab, etanercept, or infliximab. Similarly, a 2020 study of patients with psoriasis from the British Association of Dermatologists Biologics and Immunomodulators Register found that both ustekinumab and secukinumab had better sustained drug survival than did adalimumab.


Accessibility weighs heavily in using TNF inhibitor first

Clinical trials data show that IL-17 inhibitors outperform TNF inhibitors for psoriasis, but in clinical practice, TNF inhibitors still perform very well in individual patients and are well tolerated, said Amit Garg, MD, founding chair of the department of dermatology at Hofstra University, Hempstead, N.Y.

He argued in favor of TNF inhibitors as first-line therapy over IL-17 inhibitors for psoriasis. In this case, treatment decisions often come down to accessibility, Dr. Garg said. Not all insurance companies cover the cost of the newer IL-23 inhibitors. Plus, access to TNF inhibitors is widespread and costs are generally lower.

“As a physician, I don’t have complete autonomy in prescribing what I want. The reality is whether it be because of cross indication or discount pricing, [TNF inhibitors] – in particular adalimumab – is widely available on all plans and is usually the preferred treatment plan, at least in our area,” he said. “I’m not a big fan of plans that allow drugs at low or no cost for a year or 2, and then abandon the patients at that point thereafter. I like to use something that insurance will cover sustainably, and, quite frankly, TNFs have served well in that regard.”

However, TNF inhibitors are associated with more safety signals, plus they carry a greater risk of infection, leading to tolerability and persistence issues with patients.

“Psoriasis is a lifelong disease. I wish I could tell you that every drug is going to work well forever for individual patients, but I don’t think we know that yet. From my perspective, for efficacy, general well tolerance, convenience, and access, TNFs are still an important part of our ability to treat psoriasis effectively. I have no problem starting there and transitioning as needed for individual patients.

“In my experience, I think patients on TNFs generally do well. We don’t always get the patients clear and certainly there’s drop off of efficacy over time, but I’m not sure that’s a rationale for [changing treatment],” Dr. Garg said.

Ying Ying (Katy) Leung, MD, a rheumatologist with Singapore General Hospital, and a member of the GRAPPA peripheral arthritis working group, argued against the use of IL-17 and IL-23 inhibitors as first-line treatment for PsA over TNF inhibitors. She reasoned that TNF blockers are more accessible, have more long-term safety data (including data indicating safety during pregnancy), and have better cardiovascular protection. She also noted that GRAPPA treatment recommendations strongly advise using TNF blockers (or IL-17 inhibitors) for treatment-naive patients with PsA.

“Accessibility is very important as I learned along the way of leading the peripheral arthritis [GRAPPA] working group. Accessibility [issues] can be coming from a lot of sources, but if you don’t take good care of accessibility, you might be developing a guideline that is way out of reality and nobody is going to use it,” she said.

In her native Singapore, Dr. Leung said that patients pay for biologics out of pocket, so cost is a key factor for her patients. She stated that adalimumab is available as a biosimilar at about $200 monthly for patients with PsA in Singapore, while the average monthly costs are $1,400 for originator infliximab and $1,500 for originator etanercept. By comparison, secukinumab sells for about $750 monthly, ixekizumab $540 monthly, and guselkumab $2,000 monthly.

Treatment choices should be aligned with the disease manifestations of PsA, Dr. Leung said, keeping in mind that accessibility and individual patient needs and preferences should be considered as well. She conducted an informal comparison that found TNF inhibitors are most effective for patients with uveitis or inflammatory bowel disease. Evidence from head-to-head studies indicates that TNF inhibitors and IL-17 inhibitors have similar efficacy for peripheral arthritis, enthesitis, and dactylitis. But caution is warranted, she suggested, for determining the best biologics for axial disease because no head-to-head comparison trials have been conducted for IL-17 or IL-23 inhibitors versus TNF inhibitors.

Dr. Armstrong has been a consultant to AbbVie, Bristol-Myers Squibb, Dermira, Genzyme, Incyte, Janssen, Leo Pharma, Eli Lilly, Novartis, Pfizer, and UCB. Dr. Jadon has been a consultant to, has been on speakers bureaus for, and has received grant/research support from AbbVie, Amgen, Celgene, Celltrion, Gilead, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB. Dr. Garg has consulted for AbbVie, Boehringer Ingelheim, Janssen, and UCB. Dr. Leung has been a consultant to AbbVie, Boehringer Ingelheim, Janssen, Eli Lilly, Novartis, and Pfizer. She has been on speakers bureaus for AbbVie, Janssen Eli Lilly, and Novartis. She has received grant/research support from Pfizer and conference support from AbbVie,

Tumor necrosis factor inhibitors have long been the go-to treatment of choice for patients with psoriasis and psoriatic arthritis (PsA). They’ve served patients well since etanercept was first approved for PsA in 2002, but today, with the availability of more attractive interleukin-17 and IL-23 inhibitors, dermatologists and rheumatologists are asking whether it’s time to reconsider the use of TNF inhibitors as first-line therapy in psoriasis and PsA.

“TNF inhibitors have served psoriasis patients well for many years. The question is, ‘Is it time to move on from them as first-line agents for psoriasis?’ ” said April W. Armstrong, MD, MPH, a dermatologist and associate dean for clinical research at the University of Southern California, Los Angeles. Dr. Armstrong participated in a point/counterpoint debate about the merits of IL-17 and IL-23 inhibitors over TNF inhibitors at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. “For the majority of our patients, IL-17 and IL-23 inhibitors are probably rationally better than TNF inhibitors as first-line agents for moderate to severe plaque psoriasis,” she said.

In this debate, dermatologists and rheumatologists cited studies showing the safety and efficacy of IL-17 and IL-23 inhibitors over TNF inhibitors. TNF inhibitors include etanercept (Enbrel and biosimilars), infliximab (Remicade and biosimilars), adalimumab (Humira and biosimilars), certolizumab pegol (Cimzia), and golimumab (Simponi). IL-12/23 inhibitors are limited to ustekinumab (Stelara). IL-17 inhibitors include secukinumab (Cosentyx), ixekizumab (Taltz), and brodalumab (Siliq). IL-23 inhibitors include guselkumab (Tremfya), tildrakizumab (Ilumya), and risankizumab (Skyrizi).

TNF inhibitors are recommended by the American College of Rheumatology as first-line therapy for treatment-naive patients with active PsA, and they, along with IL-12/23, IL-17, and IL-23 inhibitors are all recommended by the American Academy of Dermatology as monotherapy treatment options in adult patients with moderate to severe plaque psoriasis. However, some studies have shown that non–TNF-inhibitor biologics have a higher efficacy than TNF inhibitors in some cases for some patients, such as those with moderate to severe psoriasis alone or for musculoskeletal efficacy in patients with PsA who have peripheral arthritis, enthesitis, dactylitis, or axial manifestations.

Favorable characteristics of non–TNF-inhibitor biologics

Dr. Armstrong cited a number of head-to-head trials to support her view that IL-17 and IL-23 inhibitors are better than TNF inhibitors as first-line agents for patients with moderate to severe plaque psoriasis. In the first head-to-head study of its kind in patients with moderate to severe psoriasis, ustekinumab proved superior to etanercept. Guselkumab was shown to be superior to adalimumab for patients with moderate to severe psoriasis. Tildrakizumab also proved superior to etanercept for patients with psoriasis. Risankizumab bested adalimumab in patients with moderate to severe psoriasis. Ixekizumab proved superior to etanercept in two pivotal studies of patients with widespread moderate-to-severe psoriasis.

IL-23 and IL-17 inhibitors tend to have less frequent maintenance dosing, with IL-17 inhibitors being once every 2 or 4 weeks and IL-23 inhibitors once every 8 or 12 weeks, compared with frequencies ranging from every week to every 8 weeks with TNF inhibitors, Dr. Armstrong said.

IL-17 and IL-23 inhibitors also appear to have fewer safety concerns than TNF inhibitors, although there is less long-term data for them overall and there are some notable exceptions in certain patient populations. TNF inhibitors should be avoided in patients with a history of demyelinating disease or hepatitis B virus infection, and they are not preferred in patients who have a history of latent tuberculosis or advanced heart failure. IL-17 inhibitors should not be used in patients with a history of inflammatory bowel disease, and their use is associated with a higher rate of oral candidiasis. IL-23 inhibitors have a good safety profile overall, she said.

“The IL-17/23 axis is very important to psoriatic arthritis and should be the focus of our treatments” for PsA, said Deepak Jadon, MBBCh, MRCP, PhD, a rheumatologist and director of the rheumatology research unit at Addenbrooke’s Hospital, Cambridge (England) University Hospitals NHS Foundation Trust. In his presentation, he proposed that IL-17 inhibitors and IL-23 inhibitors be used as first-line therapies in PsA ahead of TNF inhibitors.

One reason to go with IL-17 and IL-23 inhibitors may be to ”get it right immunologically the first time,” Dr. Jadon said. He cited evidence showing substantially better response to guselkumab when given to biologic-naive patients with PsA versus those who had a inadequate response to TNF inhibitors, as well as data indicating better response with secukinumab regardless of previous TNF inhibitor use.

IL-17 inhibitors target more domains of psoriatic disease than do TNF inhibitors, he said, noting that “they have excellent musculoskeletal efficacy in patients with moderate skin psoriasis, not just those with severe psoriasis.” Ixekizumab proved superior to adalimumab in biologic-naive patients with PsA. The results of this study also indicated that IL-17 inhibitors should not be reserved only for patients with severe psoriasis since a higher percentage of patients with moderate psoriasis who were taking ixekizumab achieved very low PsA activity. Secukinumab also beat adalimumab in a head-to-head comparison and showed a greater impact on some measures of health-related quality of life.

IL-17 inhibitors also do not require concomitant methotrexate, he said, “which is a major bonus for our patients. All of my patients wish to stop methotrexate even if tolerated. Not having to cope with prescribed methotrexate improves risk of adverse events and frequency of blood test monitoring.”

IL-17 and IL-23 inhibitors appear to have good efficacy against axial disease in patients with PsA. Randomized trial results for secukinumab versus placebo show high percentages of patients improving either 20% or 40% in Assessment in Spondyloarthritis International Society response criteria and reduced inflammatory MRI lesions in the spine and sacroiliac joints. Analyses of trial results in guselkumab-treated patients with axial manifestations of PsA have shown the IL-23 inhibitor’s efficacy versus placebo across different measures of disease activity.

Dr. Jadon also cited real-world data showing that patients stay longer on IL-17 and IL-12/23 inhibitors versus TNF inhibitors. A 2016 study of patients with psoriasis in the PSOLAR registry showed that patients persisted on treatment longer with ustekinumab than with adalimumab, etanercept, or infliximab. Similarly, a 2020 study of patients with psoriasis from the British Association of Dermatologists Biologics and Immunomodulators Register found that both ustekinumab and secukinumab had better sustained drug survival than did adalimumab.


Accessibility weighs heavily in using TNF inhibitor first

Clinical trials data show that IL-17 inhibitors outperform TNF inhibitors for psoriasis, but in clinical practice, TNF inhibitors still perform very well in individual patients and are well tolerated, said Amit Garg, MD, founding chair of the department of dermatology at Hofstra University, Hempstead, N.Y.

He argued in favor of TNF inhibitors as first-line therapy over IL-17 inhibitors for psoriasis. In this case, treatment decisions often come down to accessibility, Dr. Garg said. Not all insurance companies cover the cost of the newer IL-23 inhibitors. Plus, access to TNF inhibitors is widespread and costs are generally lower.

“As a physician, I don’t have complete autonomy in prescribing what I want. The reality is whether it be because of cross indication or discount pricing, [TNF inhibitors] – in particular adalimumab – is widely available on all plans and is usually the preferred treatment plan, at least in our area,” he said. “I’m not a big fan of plans that allow drugs at low or no cost for a year or 2, and then abandon the patients at that point thereafter. I like to use something that insurance will cover sustainably, and, quite frankly, TNFs have served well in that regard.”

However, TNF inhibitors are associated with more safety signals, plus they carry a greater risk of infection, leading to tolerability and persistence issues with patients.

“Psoriasis is a lifelong disease. I wish I could tell you that every drug is going to work well forever for individual patients, but I don’t think we know that yet. From my perspective, for efficacy, general well tolerance, convenience, and access, TNFs are still an important part of our ability to treat psoriasis effectively. I have no problem starting there and transitioning as needed for individual patients.

“In my experience, I think patients on TNFs generally do well. We don’t always get the patients clear and certainly there’s drop off of efficacy over time, but I’m not sure that’s a rationale for [changing treatment],” Dr. Garg said.

Ying Ying (Katy) Leung, MD, a rheumatologist with Singapore General Hospital, and a member of the GRAPPA peripheral arthritis working group, argued against the use of IL-17 and IL-23 inhibitors as first-line treatment for PsA over TNF inhibitors. She reasoned that TNF blockers are more accessible, have more long-term safety data (including data indicating safety during pregnancy), and have better cardiovascular protection. She also noted that GRAPPA treatment recommendations strongly advise using TNF blockers (or IL-17 inhibitors) for treatment-naive patients with PsA.

“Accessibility is very important as I learned along the way of leading the peripheral arthritis [GRAPPA] working group. Accessibility [issues] can be coming from a lot of sources, but if you don’t take good care of accessibility, you might be developing a guideline that is way out of reality and nobody is going to use it,” she said.

In her native Singapore, Dr. Leung said that patients pay for biologics out of pocket, so cost is a key factor for her patients. She stated that adalimumab is available as a biosimilar at about $200 monthly for patients with PsA in Singapore, while the average monthly costs are $1,400 for originator infliximab and $1,500 for originator etanercept. By comparison, secukinumab sells for about $750 monthly, ixekizumab $540 monthly, and guselkumab $2,000 monthly.

Treatment choices should be aligned with the disease manifestations of PsA, Dr. Leung said, keeping in mind that accessibility and individual patient needs and preferences should be considered as well. She conducted an informal comparison that found TNF inhibitors are most effective for patients with uveitis or inflammatory bowel disease. Evidence from head-to-head studies indicates that TNF inhibitors and IL-17 inhibitors have similar efficacy for peripheral arthritis, enthesitis, and dactylitis. But caution is warranted, she suggested, for determining the best biologics for axial disease because no head-to-head comparison trials have been conducted for IL-17 or IL-23 inhibitors versus TNF inhibitors.

Dr. Armstrong has been a consultant to AbbVie, Bristol-Myers Squibb, Dermira, Genzyme, Incyte, Janssen, Leo Pharma, Eli Lilly, Novartis, Pfizer, and UCB. Dr. Jadon has been a consultant to, has been on speakers bureaus for, and has received grant/research support from AbbVie, Amgen, Celgene, Celltrion, Gilead, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB. Dr. Garg has consulted for AbbVie, Boehringer Ingelheim, Janssen, and UCB. Dr. Leung has been a consultant to AbbVie, Boehringer Ingelheim, Janssen, Eli Lilly, Novartis, and Pfizer. She has been on speakers bureaus for AbbVie, Janssen Eli Lilly, and Novartis. She has received grant/research support from Pfizer and conference support from AbbVie,

Tumor necrosis factor inhibitors have long been the go-to treatment of choice for patients with psoriasis and psoriatic arthritis (PsA). They’ve served patients well since etanercept was first approved for PsA in 2002, but today, with the availability of more attractive interleukin-17 and IL-23 inhibitors, dermatologists and rheumatologists are asking whether it’s time to reconsider the use of TNF inhibitors as first-line therapy in psoriasis and PsA.

“TNF inhibitors have served psoriasis patients well for many years. The question is, ‘Is it time to move on from them as first-line agents for psoriasis?’ ” said April W. Armstrong, MD, MPH, a dermatologist and associate dean for clinical research at the University of Southern California, Los Angeles. Dr. Armstrong participated in a point/counterpoint debate about the merits of IL-17 and IL-23 inhibitors over TNF inhibitors at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. “For the majority of our patients, IL-17 and IL-23 inhibitors are probably rationally better than TNF inhibitors as first-line agents for moderate to severe plaque psoriasis,” she said.

In this debate, dermatologists and rheumatologists cited studies showing the safety and efficacy of IL-17 and IL-23 inhibitors over TNF inhibitors. TNF inhibitors include etanercept (Enbrel and biosimilars), infliximab (Remicade and biosimilars), adalimumab (Humira and biosimilars), certolizumab pegol (Cimzia), and golimumab (Simponi). IL-12/23 inhibitors are limited to ustekinumab (Stelara). IL-17 inhibitors include secukinumab (Cosentyx), ixekizumab (Taltz), and brodalumab (Siliq). IL-23 inhibitors include guselkumab (Tremfya), tildrakizumab (Ilumya), and risankizumab (Skyrizi).

TNF inhibitors are recommended by the American College of Rheumatology as first-line therapy for treatment-naive patients with active PsA, and they, along with IL-12/23, IL-17, and IL-23 inhibitors are all recommended by the American Academy of Dermatology as monotherapy treatment options in adult patients with moderate to severe plaque psoriasis. However, some studies have shown that non–TNF-inhibitor biologics have a higher efficacy than TNF inhibitors in some cases for some patients, such as those with moderate to severe psoriasis alone or for musculoskeletal efficacy in patients with PsA who have peripheral arthritis, enthesitis, dactylitis, or axial manifestations.

Favorable characteristics of non–TNF-inhibitor biologics

Dr. Armstrong cited a number of head-to-head trials to support her view that IL-17 and IL-23 inhibitors are better than TNF inhibitors as first-line agents for patients with moderate to severe plaque psoriasis. In the first head-to-head study of its kind in patients with moderate to severe psoriasis, ustekinumab proved superior to etanercept. Guselkumab was shown to be superior to adalimumab for patients with moderate to severe psoriasis. Tildrakizumab also proved superior to etanercept for patients with psoriasis. Risankizumab bested adalimumab in patients with moderate to severe psoriasis. Ixekizumab proved superior to etanercept in two pivotal studies of patients with widespread moderate-to-severe psoriasis.

IL-23 and IL-17 inhibitors tend to have less frequent maintenance dosing, with IL-17 inhibitors being once every 2 or 4 weeks and IL-23 inhibitors once every 8 or 12 weeks, compared with frequencies ranging from every week to every 8 weeks with TNF inhibitors, Dr. Armstrong said.

IL-17 and IL-23 inhibitors also appear to have fewer safety concerns than TNF inhibitors, although there is less long-term data for them overall and there are some notable exceptions in certain patient populations. TNF inhibitors should be avoided in patients with a history of demyelinating disease or hepatitis B virus infection, and they are not preferred in patients who have a history of latent tuberculosis or advanced heart failure. IL-17 inhibitors should not be used in patients with a history of inflammatory bowel disease, and their use is associated with a higher rate of oral candidiasis. IL-23 inhibitors have a good safety profile overall, she said.

“The IL-17/23 axis is very important to psoriatic arthritis and should be the focus of our treatments” for PsA, said Deepak Jadon, MBBCh, MRCP, PhD, a rheumatologist and director of the rheumatology research unit at Addenbrooke’s Hospital, Cambridge (England) University Hospitals NHS Foundation Trust. In his presentation, he proposed that IL-17 inhibitors and IL-23 inhibitors be used as first-line therapies in PsA ahead of TNF inhibitors.

One reason to go with IL-17 and IL-23 inhibitors may be to ”get it right immunologically the first time,” Dr. Jadon said. He cited evidence showing substantially better response to guselkumab when given to biologic-naive patients with PsA versus those who had a inadequate response to TNF inhibitors, as well as data indicating better response with secukinumab regardless of previous TNF inhibitor use.

IL-17 inhibitors target more domains of psoriatic disease than do TNF inhibitors, he said, noting that “they have excellent musculoskeletal efficacy in patients with moderate skin psoriasis, not just those with severe psoriasis.” Ixekizumab proved superior to adalimumab in biologic-naive patients with PsA. The results of this study also indicated that IL-17 inhibitors should not be reserved only for patients with severe psoriasis since a higher percentage of patients with moderate psoriasis who were taking ixekizumab achieved very low PsA activity. Secukinumab also beat adalimumab in a head-to-head comparison and showed a greater impact on some measures of health-related quality of life.

IL-17 inhibitors also do not require concomitant methotrexate, he said, “which is a major bonus for our patients. All of my patients wish to stop methotrexate even if tolerated. Not having to cope with prescribed methotrexate improves risk of adverse events and frequency of blood test monitoring.”

IL-17 and IL-23 inhibitors appear to have good efficacy against axial disease in patients with PsA. Randomized trial results for secukinumab versus placebo show high percentages of patients improving either 20% or 40% in Assessment in Spondyloarthritis International Society response criteria and reduced inflammatory MRI lesions in the spine and sacroiliac joints. Analyses of trial results in guselkumab-treated patients with axial manifestations of PsA have shown the IL-23 inhibitor’s efficacy versus placebo across different measures of disease activity.

Dr. Jadon also cited real-world data showing that patients stay longer on IL-17 and IL-12/23 inhibitors versus TNF inhibitors. A 2016 study of patients with psoriasis in the PSOLAR registry showed that patients persisted on treatment longer with ustekinumab than with adalimumab, etanercept, or infliximab. Similarly, a 2020 study of patients with psoriasis from the British Association of Dermatologists Biologics and Immunomodulators Register found that both ustekinumab and secukinumab had better sustained drug survival than did adalimumab.


Accessibility weighs heavily in using TNF inhibitor first

Clinical trials data show that IL-17 inhibitors outperform TNF inhibitors for psoriasis, but in clinical practice, TNF inhibitors still perform very well in individual patients and are well tolerated, said Amit Garg, MD, founding chair of the department of dermatology at Hofstra University, Hempstead, N.Y.

He argued in favor of TNF inhibitors as first-line therapy over IL-17 inhibitors for psoriasis. In this case, treatment decisions often come down to accessibility, Dr. Garg said. Not all insurance companies cover the cost of the newer IL-23 inhibitors. Plus, access to TNF inhibitors is widespread and costs are generally lower.

“As a physician, I don’t have complete autonomy in prescribing what I want. The reality is whether it be because of cross indication or discount pricing, [TNF inhibitors] – in particular adalimumab – is widely available on all plans and is usually the preferred treatment plan, at least in our area,” he said. “I’m not a big fan of plans that allow drugs at low or no cost for a year or 2, and then abandon the patients at that point thereafter. I like to use something that insurance will cover sustainably, and, quite frankly, TNFs have served well in that regard.”

However, TNF inhibitors are associated with more safety signals, plus they carry a greater risk of infection, leading to tolerability and persistence issues with patients.

“Psoriasis is a lifelong disease. I wish I could tell you that every drug is going to work well forever for individual patients, but I don’t think we know that yet. From my perspective, for efficacy, general well tolerance, convenience, and access, TNFs are still an important part of our ability to treat psoriasis effectively. I have no problem starting there and transitioning as needed for individual patients.

“In my experience, I think patients on TNFs generally do well. We don’t always get the patients clear and certainly there’s drop off of efficacy over time, but I’m not sure that’s a rationale for [changing treatment],” Dr. Garg said.

Ying Ying (Katy) Leung, MD, a rheumatologist with Singapore General Hospital, and a member of the GRAPPA peripheral arthritis working group, argued against the use of IL-17 and IL-23 inhibitors as first-line treatment for PsA over TNF inhibitors. She reasoned that TNF blockers are more accessible, have more long-term safety data (including data indicating safety during pregnancy), and have better cardiovascular protection. She also noted that GRAPPA treatment recommendations strongly advise using TNF blockers (or IL-17 inhibitors) for treatment-naive patients with PsA.

“Accessibility is very important as I learned along the way of leading the peripheral arthritis [GRAPPA] working group. Accessibility [issues] can be coming from a lot of sources, but if you don’t take good care of accessibility, you might be developing a guideline that is way out of reality and nobody is going to use it,” she said.

In her native Singapore, Dr. Leung said that patients pay for biologics out of pocket, so cost is a key factor for her patients. She stated that adalimumab is available as a biosimilar at about $200 monthly for patients with PsA in Singapore, while the average monthly costs are $1,400 for originator infliximab and $1,500 for originator etanercept. By comparison, secukinumab sells for about $750 monthly, ixekizumab $540 monthly, and guselkumab $2,000 monthly.

Treatment choices should be aligned with the disease manifestations of PsA, Dr. Leung said, keeping in mind that accessibility and individual patient needs and preferences should be considered as well. She conducted an informal comparison that found TNF inhibitors are most effective for patients with uveitis or inflammatory bowel disease. Evidence from head-to-head studies indicates that TNF inhibitors and IL-17 inhibitors have similar efficacy for peripheral arthritis, enthesitis, and dactylitis. But caution is warranted, she suggested, for determining the best biologics for axial disease because no head-to-head comparison trials have been conducted for IL-17 or IL-23 inhibitors versus TNF inhibitors.

Dr. Armstrong has been a consultant to AbbVie, Bristol-Myers Squibb, Dermira, Genzyme, Incyte, Janssen, Leo Pharma, Eli Lilly, Novartis, Pfizer, and UCB. Dr. Jadon has been a consultant to, has been on speakers bureaus for, and has received grant/research support from AbbVie, Amgen, Celgene, Celltrion, Gilead, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB. Dr. Garg has consulted for AbbVie, Boehringer Ingelheim, Janssen, and UCB. Dr. Leung has been a consultant to AbbVie, Boehringer Ingelheim, Janssen, Eli Lilly, Novartis, and Pfizer. She has been on speakers bureaus for AbbVie, Janssen Eli Lilly, and Novartis. She has received grant/research support from Pfizer and conference support from AbbVie,

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

Key clinical point: Among patients with psoriatic arthritis (PsA), risk for major adverse cardiovascular events (MACEs) was higher in those who initiated interleukin (IL)12/23 and IL17 inhibitors vs tumor necrosis factor (TNF) inhibitors. However, risk for MACEs was not different among new-users of TNF inhibitors or apremilast.

Major finding: Overall, 51 MACEs (crude incidence rate, 3.4/1,000 patient-years) were observed. The risk of MACEs was higher (P less than .0001) with IL12/23 (weighted hazard ratio [wHR], 2.0; 95% confidence interval [CI], 1.3-3.0) and IL17 (wHR, 1.9; 95% CI, 1.2-3.0) inhibitors but not with apremilast (wHR, 1.3; 95% CI, 0.8-2.2) vs TNF inhibitors.

Study details: Findings are from a nationwide PsA cohort without a history of cardiovascular diseases involving 9,510 new users of biological disease-modifying anti-rheumatic drugs (TNF inhibitor, n=7289; IL12/23 inhibitor, n=1058; IL17 inhibitor, n=1,163) and 1,885 new users of apremilast.

Disclosures: The study did not receive any funding. P Claudepierre reported receiving consulting fees from and being an investigator for various pharmaceutical companies. Other authors declared no conflicts of interest.

Source: Vegas LP et al. Rheumatology. 2021 Jul 9. doi: 10.1093/rheumatology/keab522.

Key clinical point: Among patients with psoriatic arthritis (PsA), risk for major adverse cardiovascular events (MACEs) was higher in those who initiated interleukin (IL)12/23 and IL17 inhibitors vs tumor necrosis factor (TNF) inhibitors. However, risk for MACEs was not different among new-users of TNF inhibitors or apremilast.

Major finding: Overall, 51 MACEs (crude incidence rate, 3.4/1,000 patient-years) were observed. The risk of MACEs was higher (P less than .0001) with IL12/23 (weighted hazard ratio [wHR], 2.0; 95% confidence interval [CI], 1.3-3.0) and IL17 (wHR, 1.9; 95% CI, 1.2-3.0) inhibitors but not with apremilast (wHR, 1.3; 95% CI, 0.8-2.2) vs TNF inhibitors.

Study details: Findings are from a nationwide PsA cohort without a history of cardiovascular diseases involving 9,510 new users of biological disease-modifying anti-rheumatic drugs (TNF inhibitor, n=7289; IL12/23 inhibitor, n=1058; IL17 inhibitor, n=1,163) and 1,885 new users of apremilast.

Disclosures: The study did not receive any funding. P Claudepierre reported receiving consulting fees from and being an investigator for various pharmaceutical companies. Other authors declared no conflicts of interest.

Source: Vegas LP et al. Rheumatology. 2021 Jul 9. doi: 10.1093/rheumatology/keab522.

Key clinical point: Among patients with psoriatic arthritis (PsA), risk for major adverse cardiovascular events (MACEs) was higher in those who initiated interleukin (IL)12/23 and IL17 inhibitors vs tumor necrosis factor (TNF) inhibitors. However, risk for MACEs was not different among new-users of TNF inhibitors or apremilast.

Major finding: Overall, 51 MACEs (crude incidence rate, 3.4/1,000 patient-years) were observed. The risk of MACEs was higher (P less than .0001) with IL12/23 (weighted hazard ratio [wHR], 2.0; 95% confidence interval [CI], 1.3-3.0) and IL17 (wHR, 1.9; 95% CI, 1.2-3.0) inhibitors but not with apremilast (wHR, 1.3; 95% CI, 0.8-2.2) vs TNF inhibitors.

Study details: Findings are from a nationwide PsA cohort without a history of cardiovascular diseases involving 9,510 new users of biological disease-modifying anti-rheumatic drugs (TNF inhibitor, n=7289; IL12/23 inhibitor, n=1058; IL17 inhibitor, n=1,163) and 1,885 new users of apremilast.

Disclosures: The study did not receive any funding. P Claudepierre reported receiving consulting fees from and being an investigator for various pharmaceutical companies. Other authors declared no conflicts of interest.

Source: Vegas LP et al. Rheumatology. 2021 Jul 9. doi: 10.1093/rheumatology/keab522.

Key clinical point: The drug survival rate was good for the first biological disease-modifying antirheumatic drug (bDMARD) in patients with psoriatic arthritis (PsA). Moreover, female sex may be a predisposing risk factor for flares and therapeutic switches.

Major finding: Overall, 44.32% of patients switched to another bDMARD. The mean time to first bDMARD discontinuation was 72 months. Overall, the drug survival rate in patients treated with antitumor necrosis factor-α and anti-interleukin (IL)-12/23 or anti-IL17 was 75% at 2 years and 60% at 5 years without a significant difference between the biological agents (P = .66). Female sex was associated with a higher risk for first bDMARD discontinuation (hazard ratio, 2.39; 95% confidence interval, 1.50-3.81).

Study details: The data come from a 15-year, monocentric, real-life study involving 264 patients with PsA who received biologics treatment.

Disclosures: The study reported no external funding. R Ramonda and A Doria reported receiving honoraria and speaker fees from Novartis, AbbVie, Pfizer, MSD, and Janssen. All the other authors declared no conflicts of interest.

Source: Lorenzin M et al. Clin Rheumatol. 2021 Jun 16. doi: 10.1007/s10067-021-05799-0.

Key clinical point: The drug survival rate was good for the first biological disease-modifying antirheumatic drug (bDMARD) in patients with psoriatic arthritis (PsA). Moreover, female sex may be a predisposing risk factor for flares and therapeutic switches.

Major finding: Overall, 44.32% of patients switched to another bDMARD. The mean time to first bDMARD discontinuation was 72 months. Overall, the drug survival rate in patients treated with antitumor necrosis factor-α and anti-interleukin (IL)-12/23 or anti-IL17 was 75% at 2 years and 60% at 5 years without a significant difference between the biological agents (P = .66). Female sex was associated with a higher risk for first bDMARD discontinuation (hazard ratio, 2.39; 95% confidence interval, 1.50-3.81).

Study details: The data come from a 15-year, monocentric, real-life study involving 264 patients with PsA who received biologics treatment.

Disclosures: The study reported no external funding. R Ramonda and A Doria reported receiving honoraria and speaker fees from Novartis, AbbVie, Pfizer, MSD, and Janssen. All the other authors declared no conflicts of interest.

Source: Lorenzin M et al. Clin Rheumatol. 2021 Jun 16. doi: 10.1007/s10067-021-05799-0.

Key clinical point: The drug survival rate was good for the first biological disease-modifying antirheumatic drug (bDMARD) in patients with psoriatic arthritis (PsA). Moreover, female sex may be a predisposing risk factor for flares and therapeutic switches.

Major finding: Overall, 44.32% of patients switched to another bDMARD. The mean time to first bDMARD discontinuation was 72 months. Overall, the drug survival rate in patients treated with antitumor necrosis factor-α and anti-interleukin (IL)-12/23 or anti-IL17 was 75% at 2 years and 60% at 5 years without a significant difference between the biological agents (P = .66). Female sex was associated with a higher risk for first bDMARD discontinuation (hazard ratio, 2.39; 95% confidence interval, 1.50-3.81).

Study details: The data come from a 15-year, monocentric, real-life study involving 264 patients with PsA who received biologics treatment.

Disclosures: The study reported no external funding. R Ramonda and A Doria reported receiving honoraria and speaker fees from Novartis, AbbVie, Pfizer, MSD, and Janssen. All the other authors declared no conflicts of interest.

Source: Lorenzin M et al. Clin Rheumatol. 2021 Jun 16. doi: 10.1007/s10067-021-05799-0.

Key clinical point: Treatment with biological disease-modifying antirheumatic drugs (bDMARDs) was associated with a significantly lower incidence of psoriatic arthritis (PsA) compared with narrow-band ultraviolet light B (nb-UVB) phototherapy in patients with moderate-to-severe chronic plaque psoriasis.

Major finding: The annual incidence rate for PsA was lower in patients prescribed bDMARDs vs phototherapy (1.20 vs 2.17 cases per 100 patients/year; P = .006). Treatment with bDMARD was associated with a lower risk for incident PsA (adjusted hazard ratio, 0.27; P = .004).

Study details: The data come from a retrospective, nonrandomized study involving 464 patients with moderate-to-severe plaque psoriasis who were prescribed either at least 5 years of bDMARDs (n=234) or at least 3 nb-UVB phototherapy courses (n=230).

Disclosures: This work was supported by the European Union’s Horizon 2020 Research and Innovation Program. P Gisondi, L Idolazzi, and G Girolomoni reported receiving consultancy and/or speaker fees from various sources.

Source: Gisondi P et al. Ann Rheum Dis. 2021 Jun 18. doi: 10.1136/annrheumdis-2021-219961.

Key clinical point: Treatment with biological disease-modifying antirheumatic drugs (bDMARDs) was associated with a significantly lower incidence of psoriatic arthritis (PsA) compared with narrow-band ultraviolet light B (nb-UVB) phototherapy in patients with moderate-to-severe chronic plaque psoriasis.

Major finding: The annual incidence rate for PsA was lower in patients prescribed bDMARDs vs phototherapy (1.20 vs 2.17 cases per 100 patients/year; P = .006). Treatment with bDMARD was associated with a lower risk for incident PsA (adjusted hazard ratio, 0.27; P = .004).

Study details: The data come from a retrospective, nonrandomized study involving 464 patients with moderate-to-severe plaque psoriasis who were prescribed either at least 5 years of bDMARDs (n=234) or at least 3 nb-UVB phototherapy courses (n=230).

Disclosures: This work was supported by the European Union’s Horizon 2020 Research and Innovation Program. P Gisondi, L Idolazzi, and G Girolomoni reported receiving consultancy and/or speaker fees from various sources.

Source: Gisondi P et al. Ann Rheum Dis. 2021 Jun 18. doi: 10.1136/annrheumdis-2021-219961.

Key clinical point: Treatment with biological disease-modifying antirheumatic drugs (bDMARDs) was associated with a significantly lower incidence of psoriatic arthritis (PsA) compared with narrow-band ultraviolet light B (nb-UVB) phototherapy in patients with moderate-to-severe chronic plaque psoriasis.

Major finding: The annual incidence rate for PsA was lower in patients prescribed bDMARDs vs phototherapy (1.20 vs 2.17 cases per 100 patients/year; P = .006). Treatment with bDMARD was associated with a lower risk for incident PsA (adjusted hazard ratio, 0.27; P = .004).

Study details: The data come from a retrospective, nonrandomized study involving 464 patients with moderate-to-severe plaque psoriasis who were prescribed either at least 5 years of bDMARDs (n=234) or at least 3 nb-UVB phototherapy courses (n=230).

Disclosures: This work was supported by the European Union’s Horizon 2020 Research and Innovation Program. P Gisondi, L Idolazzi, and G Girolomoni reported receiving consultancy and/or speaker fees from various sources.

Source: Gisondi P et al. Ann Rheum Dis. 2021 Jun 18. doi: 10.1136/annrheumdis-2021-219961.

Key clinical point: Among patients with psoriatic arthritis (PsA), those receiving tofacitinib experienced more rapid pain improvement compared with placebo.

Major finding: Median days to 30% or higher and 50% or higher initial pain improvement in patients receiving tofacitinib vs those switching from placebo to tofacitinib was 55.0 (95% confidence interval [CI], 29.0-57.0) vs 106.0 (95% CI, 64.0-115.0) and 85.0 (95% CI, 57.0-92.0) vs 169.0 (95% CI, 120.0-189.0), respectively.

Study details: This was a post hoc analysis of 2 phase 3 OPAL Broaden and OPAL Beyond trials involving 238 patients with active PsA randomly assigned to receive tofacitinib 5 mg twice daily, placebo switching to tofacitinib 5 mg twice daily at month 3 (placebo-to-tofacitinib), or adalimumab.

Disclosures: This study was funded by Pfizer Inc. Some of the authors declared serving as consultant and/or receiving grant/research support and consultancy fees from various sources including Pfizer Inc. Three authors reported being employees and stockholders of Pfizer Inc.

Source: de Vlam K et al. RMD Open. 2021 Jul 5. doi: 10.1136/rmdopen-2021-001609.

Key clinical point: Among patients with psoriatic arthritis (PsA), those receiving tofacitinib experienced more rapid pain improvement compared with placebo.

Major finding: Median days to 30% or higher and 50% or higher initial pain improvement in patients receiving tofacitinib vs those switching from placebo to tofacitinib was 55.0 (95% confidence interval [CI], 29.0-57.0) vs 106.0 (95% CI, 64.0-115.0) and 85.0 (95% CI, 57.0-92.0) vs 169.0 (95% CI, 120.0-189.0), respectively.

Study details: This was a post hoc analysis of 2 phase 3 OPAL Broaden and OPAL Beyond trials involving 238 patients with active PsA randomly assigned to receive tofacitinib 5 mg twice daily, placebo switching to tofacitinib 5 mg twice daily at month 3 (placebo-to-tofacitinib), or adalimumab.

Disclosures: This study was funded by Pfizer Inc. Some of the authors declared serving as consultant and/or receiving grant/research support and consultancy fees from various sources including Pfizer Inc. Three authors reported being employees and stockholders of Pfizer Inc.

Source: de Vlam K et al. RMD Open. 2021 Jul 5. doi: 10.1136/rmdopen-2021-001609.

Key clinical point: Among patients with psoriatic arthritis (PsA), those receiving tofacitinib experienced more rapid pain improvement compared with placebo.

Major finding: Median days to 30% or higher and 50% or higher initial pain improvement in patients receiving tofacitinib vs those switching from placebo to tofacitinib was 55.0 (95% confidence interval [CI], 29.0-57.0) vs 106.0 (95% CI, 64.0-115.0) and 85.0 (95% CI, 57.0-92.0) vs 169.0 (95% CI, 120.0-189.0), respectively.

Study details: This was a post hoc analysis of 2 phase 3 OPAL Broaden and OPAL Beyond trials involving 238 patients with active PsA randomly assigned to receive tofacitinib 5 mg twice daily, placebo switching to tofacitinib 5 mg twice daily at month 3 (placebo-to-tofacitinib), or adalimumab.

Disclosures: This study was funded by Pfizer Inc. Some of the authors declared serving as consultant and/or receiving grant/research support and consultancy fees from various sources including Pfizer Inc. Three authors reported being employees and stockholders of Pfizer Inc.

Source: de Vlam K et al. RMD Open. 2021 Jul 5. doi: 10.1136/rmdopen-2021-001609.

Key clinical point: Secukinumab improved disease burden in patients with psoriatic arthritis (PsA), regardless of previous tumor necrosis factor inhibitor (TNFi) exposure.

Major finding: Higher proportion of TNFi-naive patients receiving secukinumab 300 and 150 mg vs placebo showed resolution in 66 swollen joint count (SJC66; 41.5% and 27.7% vs 16.8%, respectively) and 68 tender joint counts (24.4% and 13.4% vs 5.7%, respectively; all P less than .05). Among patients with inadequate response to TNFi (TNFi-IR), those who received secukinumab 150 mg vs placebo experienced significant SJC66 resolution (20.8% vs 12.3%; P less than .05).

Study details: Findings are from a pooled analysis of 4 phase 3 randomized controlled trials (FUTURE 2, FUTURE 3, FUTURE 4, and FUTURE 5) involving 2049 patients with PsA who were either TNFi naive (n=1436) or TNFi-IR (n=613). Patients received either secukinumab 300 mg (n=461), secukinumab 150 mg (n=907), or placebo (n=681).

Disclosures: This study was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA. The authors including the lead author reported receiving grant support, speaker fees, and/or consulting fees from various sources. O Chambenoit and X Meng reported being employees and stockholders of Novartis.

Source: Orbai AM et al. Rheumatol Ther. 2021 Jul 3. doi: 10.1007/s40744-021-00337-5.

Key clinical point: Secukinumab improved disease burden in patients with psoriatic arthritis (PsA), regardless of previous tumor necrosis factor inhibitor (TNFi) exposure.

Major finding: Higher proportion of TNFi-naive patients receiving secukinumab 300 and 150 mg vs placebo showed resolution in 66 swollen joint count (SJC66; 41.5% and 27.7% vs 16.8%, respectively) and 68 tender joint counts (24.4% and 13.4% vs 5.7%, respectively; all P less than .05). Among patients with inadequate response to TNFi (TNFi-IR), those who received secukinumab 150 mg vs placebo experienced significant SJC66 resolution (20.8% vs 12.3%; P less than .05).

Study details: Findings are from a pooled analysis of 4 phase 3 randomized controlled trials (FUTURE 2, FUTURE 3, FUTURE 4, and FUTURE 5) involving 2049 patients with PsA who were either TNFi naive (n=1436) or TNFi-IR (n=613). Patients received either secukinumab 300 mg (n=461), secukinumab 150 mg (n=907), or placebo (n=681).

Disclosures: This study was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA. The authors including the lead author reported receiving grant support, speaker fees, and/or consulting fees from various sources. O Chambenoit and X Meng reported being employees and stockholders of Novartis.

Source: Orbai AM et al. Rheumatol Ther. 2021 Jul 3. doi: 10.1007/s40744-021-00337-5.

Key clinical point: Secukinumab improved disease burden in patients with psoriatic arthritis (PsA), regardless of previous tumor necrosis factor inhibitor (TNFi) exposure.

Major finding: Higher proportion of TNFi-naive patients receiving secukinumab 300 and 150 mg vs placebo showed resolution in 66 swollen joint count (SJC66; 41.5% and 27.7% vs 16.8%, respectively) and 68 tender joint counts (24.4% and 13.4% vs 5.7%, respectively; all P less than .05). Among patients with inadequate response to TNFi (TNFi-IR), those who received secukinumab 150 mg vs placebo experienced significant SJC66 resolution (20.8% vs 12.3%; P less than .05).

Study details: Findings are from a pooled analysis of 4 phase 3 randomized controlled trials (FUTURE 2, FUTURE 3, FUTURE 4, and FUTURE 5) involving 2049 patients with PsA who were either TNFi naive (n=1436) or TNFi-IR (n=613). Patients received either secukinumab 300 mg (n=461), secukinumab 150 mg (n=907), or placebo (n=681).

Disclosures: This study was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA. The authors including the lead author reported receiving grant support, speaker fees, and/or consulting fees from various sources. O Chambenoit and X Meng reported being employees and stockholders of Novartis.

Source: Orbai AM et al. Rheumatol Ther. 2021 Jul 3. doi: 10.1007/s40744-021-00337-5.

Key clinical point: In a real-world cohort of patients with psoriatic arthritis (PsA), achievement of treatment targets was similar after 6 months of treatment with ustekinumab or tumor necrosis factor (TNF) inhibitors.

Major finding: After 6 months of treatment, the proportion of patients achieving clinical Disease Activity Index for PsA (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.46-1.15), low disease activity (LDA; OR, 0.74; 95% CI, 0.53-1.04), minimal disease activity (OR, 0.87; 95% CI, 0.61-1.25), and very LDA (OR, 0.74; 95% CI, 0.42-1.30) was not significantly different in ustekinumab vs TNF inhibitor groups. Both the groups reported similar adverse and serious adverse events.

Study details: Findings are from an analysis of 868 patients with PsA from the observational PsABio study, who were treated with first-line to third-line ustekinumab or TNF inhibitors.

Disclosures: PsABio study was sponsored by Janssen. The authors including the lead author reported receiving grants/research support and/or personal fees from various sources including Janssen. W Noël, P Bergmans, and E Theander reported being full-time employees of Janssen.

Source: Smolen JS et al. Ann Rheum Dis. 2021 Jun 23. doi: 10.1136/annrheumdis-2021-220263.

Key clinical point: In a real-world cohort of patients with psoriatic arthritis (PsA), achievement of treatment targets was similar after 6 months of treatment with ustekinumab or tumor necrosis factor (TNF) inhibitors.

Major finding: After 6 months of treatment, the proportion of patients achieving clinical Disease Activity Index for PsA (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.46-1.15), low disease activity (LDA; OR, 0.74; 95% CI, 0.53-1.04), minimal disease activity (OR, 0.87; 95% CI, 0.61-1.25), and very LDA (OR, 0.74; 95% CI, 0.42-1.30) was not significantly different in ustekinumab vs TNF inhibitor groups. Both the groups reported similar adverse and serious adverse events.

Study details: Findings are from an analysis of 868 patients with PsA from the observational PsABio study, who were treated with first-line to third-line ustekinumab or TNF inhibitors.

Disclosures: PsABio study was sponsored by Janssen. The authors including the lead author reported receiving grants/research support and/or personal fees from various sources including Janssen. W Noël, P Bergmans, and E Theander reported being full-time employees of Janssen.

Source: Smolen JS et al. Ann Rheum Dis. 2021 Jun 23. doi: 10.1136/annrheumdis-2021-220263.

Key clinical point: In a real-world cohort of patients with psoriatic arthritis (PsA), achievement of treatment targets was similar after 6 months of treatment with ustekinumab or tumor necrosis factor (TNF) inhibitors.

Major finding: After 6 months of treatment, the proportion of patients achieving clinical Disease Activity Index for PsA (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.46-1.15), low disease activity (LDA; OR, 0.74; 95% CI, 0.53-1.04), minimal disease activity (OR, 0.87; 95% CI, 0.61-1.25), and very LDA (OR, 0.74; 95% CI, 0.42-1.30) was not significantly different in ustekinumab vs TNF inhibitor groups. Both the groups reported similar adverse and serious adverse events.

Study details: Findings are from an analysis of 868 patients with PsA from the observational PsABio study, who were treated with first-line to third-line ustekinumab or TNF inhibitors.

Disclosures: PsABio study was sponsored by Janssen. The authors including the lead author reported receiving grants/research support and/or personal fees from various sources including Janssen. W Noël, P Bergmans, and E Theander reported being full-time employees of Janssen.

Source: Smolen JS et al. Ann Rheum Dis. 2021 Jun 23. doi: 10.1136/annrheumdis-2021-220263.

Key clinical point: The composite ultrasonography scores showed a significantly greater value for assessment of disease activity than clinical scores in patients with psoriatic arthritis (PsA) with coexisting fibromyalgia syndrome (FMS).

Major finding: Patients with coexisting PsA and FMS vs those without FMS had higher scores for several disease activity indices, including Composite Psoriatic Disease Activity Index, Disease Activity for PsA, and PsA Disease Activity Score (P less than .001). However, both groups had similar total ultrasonographic scores regardless of FMS (P = .68). A significant association was observed between FMS and higher scores on clinical activity indices (P less than .001) but not with the ultrasonography score.

Study details: The data come from a prospective study of 156 patients with PsA who were categorized into those with (n=42) and without (n=114) FMS.

Disclosures: No specific funding or conflicts of interest were reported.

Source: Polachek A et al. Ann Rheum Dis. 2021 Jul 2. doi: 10.1136/annrheumdis-2021-220562.

Key clinical point: The composite ultrasonography scores showed a significantly greater value for assessment of disease activity than clinical scores in patients with psoriatic arthritis (PsA) with coexisting fibromyalgia syndrome (FMS).

Major finding: Patients with coexisting PsA and FMS vs those without FMS had higher scores for several disease activity indices, including Composite Psoriatic Disease Activity Index, Disease Activity for PsA, and PsA Disease Activity Score (P less than .001). However, both groups had similar total ultrasonographic scores regardless of FMS (P = .68). A significant association was observed between FMS and higher scores on clinical activity indices (P less than .001) but not with the ultrasonography score.

Study details: The data come from a prospective study of 156 patients with PsA who were categorized into those with (n=42) and without (n=114) FMS.

Disclosures: No specific funding or conflicts of interest were reported.

Source: Polachek A et al. Ann Rheum Dis. 2021 Jul 2. doi: 10.1136/annrheumdis-2021-220562.

Key clinical point: The composite ultrasonography scores showed a significantly greater value for assessment of disease activity than clinical scores in patients with psoriatic arthritis (PsA) with coexisting fibromyalgia syndrome (FMS).

Major finding: Patients with coexisting PsA and FMS vs those without FMS had higher scores for several disease activity indices, including Composite Psoriatic Disease Activity Index, Disease Activity for PsA, and PsA Disease Activity Score (P less than .001). However, both groups had similar total ultrasonographic scores regardless of FMS (P = .68). A significant association was observed between FMS and higher scores on clinical activity indices (P less than .001) but not with the ultrasonography score.

Study details: The data come from a prospective study of 156 patients with PsA who were categorized into those with (n=42) and without (n=114) FMS.

Disclosures: No specific funding or conflicts of interest were reported.

Source: Polachek A et al. Ann Rheum Dis. 2021 Jul 2. doi: 10.1136/annrheumdis-2021-220562.