What biologic options are suitable for a patient with psoriatic arthritis and osteoarthritis, currently on long-term prednisone (corticosteroid) and sulfasalazine (disease-modifying antirheumatic drug), presenting with new pains?

From the Guidelines

For a patient with psoriatic arthritis and osteoarthritis on long-term prednisone and sulfasalazine who is experiencing new pains, the most suitable biologic options would be tumor necrosis factor (TNF) inhibitors or interleukin inhibitors, with a preference for IL-17 inhibitors like secukinumab for skin symptoms, as recommended by the 2020 EULAR guidelines 1.

Biologic Options

• TNF inhibitors like adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), or certolizumab pegol (Cimzia) are typically first-line biologic choices.
• Interleukin inhibitors such as secukinumab (Cosentyx), ixekizumab (Taltz), or ustekinumab (Stelara) are alternative biologics.
• The JAK inhibitor tofacitinib (Xeljanz) may also be considered.

Treatment Considerations

• Before initiating any biologic therapy, the patient should undergo screening for tuberculosis, hepatitis B and C, and have up-to-date vaccinations 1.
• The choice of biologic should consider the patient's comorbidities, as some agents may offer benefits for specific manifestations of psoriatic disease.
• The goal would be to control inflammation effectively enough to eventually reduce or eliminate the need for long-term corticosteroids, which carry significant risks with prolonged use.
• The osteoarthritis component of the patient's condition would still require separate management strategies as biologics primarily target the inflammatory arthritis.

Guideline Recommendations

• The 2020 EULAR guidelines recommend aiming for remission or low disease activity by regular disease activity assessment and appropriate adjustment of therapy 1.
• The guidelines also recommend considering the use of biologic therapies in patients with psoriatic arthritis who have an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) 1.
• The 2019 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis also provides recommendations for the use of biologic therapies in patients with psoriatic arthritis 1.

From the FDA Drug Label

Rheumatoid Arthritis and Psoriatic Arthritis: Patients in Studies RA-I, RA-II, and RA-III were tested at multiple time points for antibodies to adalimumab using the ELISA during the 6- to 12-month period No apparent correlation of antibody development to adverse reactions was observed. With monotherapy, patients receiving every other week dosing may develop antibodies more frequently than those receiving weekly dosing In patients receiving the recommended dosage of 40 mg every other week as monotherapy, the ACR 20 response was lower among antibody-positive patients than among antibody-negative patients.

Biologic Options:

• Adalimumab (HUMIRA): may be a suitable option for the patient with psoriatic arthritis, as it has been studied in patients with rheumatoid arthritis and psoriatic arthritis.
• Other TNF blockers: may also be considered, but the FDA label does not provide direct information on their use in patients with both psoriatic arthritis and osteoarthritis.
• Concomitant use with other biologic DMARDS or TNF blockers: is not recommended due to the possible increased risk for infections and other potential pharmacological interactions 2 2. The patient's long-term use of prednisone and sulfasalazine should be considered when selecting a biologic option, but the FDA label does not provide direct guidance on this specific situation.

From the Research

Biologic Options for Psoriatic Arthritis and Osteoarthritis

The patient in question has been experiencing psoriatic arthritis symptoms along with osteoarthritis and has been on long-term use of 4mg prednisone and 3 grams of sulfasalazine for 15 years. Considering the new pains, biologic options can be explored for better management of the condition.

Suitable Biologics

• Secukinumab: An IL-17A inhibitor that has shown efficacy in treating psoriatic arthritis, especially in patients with concomitant moderate-to-severe plaque psoriasis 3. It can be considered as a biologic option for this patient.
• Adalimumab: A TNF-α inhibitor that has been compared with secukinumab in the EXCEED study, showing similar efficacy in treating psoriatic arthritis 4. It can be another biologic option for this patient.
• Etanercept: A TNF-α inhibitor that has been compared with infliximab and adalimumab in various studies, showing similar efficacy in treating psoriatic arthritis 5, 6.
• Infliximab: A TNF-α inhibitor that has been shown to be effective in treating psoriatic arthritis, especially in patients with inadequate response to previous disease-modifying antirheumatic drugs 6.
• Golimumab: A TNF-α inhibitor that has been compared with other biologics in various studies, showing similar efficacy in treating psoriatic arthritis 5, 7.
• Ustekinumab: An IL-12/23 antagonist that has been shown to be effective in treating psoriatic arthritis, especially in patients with concomitant moderate-to-severe plaque psoriasis 7.
• Ixekizumab: An IL-17A antagonist that has been shown to be effective in treating psoriatic arthritis 7.

Considerations

When choosing a biologic option, it's essential to consider the patient's medical history, current medications, and potential side effects. The patient's long-term use of prednisone and sulfasalazine should be taken into account when selecting a biologic agent. Additionally, the presence of osteoarthritis may require careful consideration of the biologic agent's potential effects on joint health. Consultation with a rheumatologist is recommended to determine the best course of treatment for this patient 4, 3, 5, 7, 6.