British Society for Rheumatology (BSR) 2013 Report – TNF switch works in Psoriatic Arthritis

Most patients with psoriatic arthritis responded well to a first-line biologic, but for many of those who didn’t initially respond, switching to another agent proved beneficial.

In a retrospective survey that included 548 patients, 74% showed an adequate response to treatment with a tumor necrosis factor (TNF) inhibitor at 3 months, according to Meghna Jani, MBBS, of the University of Manchester, UK, and colleagues.

And among 94 patients who switched to a second TNF inhibitor, 52% responded “very well,” she told attendees at the annual meeting of the British Society for Rheumatology.

“Anti-TNF biologics have transformed the treatment of psoriatic arthritis, with substantial evidence that they reduce disease activity. Unfortunately, some patients don’t tolerate or respond well to them at first, and may seek a second anti-TNF,” she said.

Unlike in rheumatoid arthritis, there is little randomized clinical trial evidence establishing efficacy for switching in psoriatic arthritis, and the U.K. National Institute of Clinical Excellence (NICE) has not yet endorsed the practice of using sequential biologics in psoriatic arthritis, particularly in cases of a lack of efficacy.

“Therefore, in some cases patients who fail on a TNF inhibitor may be left with no therapeutic options,” she said.

Recent open-label and registry studies have begun to suggest that switching may be beneficial, so she and her colleagues conducted a survey of real-life use of biologics in psoriatic arthritis to determine the reasons for TNF failure, whether or not clinicians are following the NICE guidelines, and, for patients who do switch, what their outcomes are.

All 18 referral centers in northwest England participated in the survey.Patients’ mean age was 49 and there was an equal gender distribution.Median time from diagnosis to starting a TNF inhibitor was 4.6 years, and mean follow-up time on the biologic was 2 years. The first-line biologic was adalimumab (Humira) in 64% of patients and etanercept (Enbrel) in slightly more than one-third.Smaller numbers of patients started treatment with infliximab (Remicade) or golimumab (Simponi).In 28%, the TNF inhibitor was given as monotherapy, and in the remainder a conventional disease-modifying anti-rheumatic drug such a methotrexate also was used.

At 3 months, 24% of patients were no longer on their initial anti-TNF therapy. The most common reason for stopping therapy, reported in 39 patients, was secondary lack of efficacy, meaning that they had initially responded but then lost the response. Inability to tolerate the drug was the reason 33 patients stopped treatment, and 25 patients never showed a response at all.”Interestingly, 14 patients reported a combination of secondary lack of efficacy and skin reactions, suggesting the possibility that immunogenicity developed in some patients,” Jani said. A few patients stopped treatment because they became pregnant. A total of 18% of patients who received a second anti-TNF agent were non responders, but 8% of the cohort went on to have a good response to a third or fourth agent.

A few patients who were unable to obtain permission to try additional therapies were reclassified as having rheumatoid arthritis with psoriasis, and were then given agents such as rituximab (Rituxan), certolizumab (Cimzia), or tocilizumab (Actemra). “This survey provides real-life data supporting the use of sequential biologics in psoriatic arthritis, which is in accordance with new BSR guidelines, and suggests that the NICE guidelines need to be updated to provide patients with more therapeutic options,” she said. Limitations of the study included its cross-sectional design and a lack of information about disease severity.

Conflict of interest:

The authors reported no conflicts of interest.

Reference:

Jani M, et al, Effectiveness of sequential biologic use in psoriatic arthritis: results of a large retrospective survey. BSR; Abstract O60.