What is the best biological therapy for a patient with ankylosing spondylitis, peripheral arthritis, and a history of renal cell carcinoma (RCC) 2 years ago, considering recent malignancy?

From the Guidelines

For a patient with ankylosing spondylitis, peripheral arthritis, and a history of renal cell carcinoma two years ago, the preferred biological therapy would be secukinumab (Cosentyx) or ixekizumab (Taltz), as they have no established association with increased malignancy risk. The patient's recent malignancy history warrants caution, and TNF inhibitors should be avoided due to their potential to promote tumor growth or recurrence 1. The treatment regimen for secukinumab would be 150 mg subcutaneously weekly for five weeks (loading dose), followed by 150 mg monthly maintenance, while ixekizumab could be used at 160 mg initially, then 80 mg every four weeks 1. Before initiating therapy, the patient should undergo tuberculosis screening, complete blood count, and liver function tests to ensure safe treatment. Regular monitoring every 3-6 months is recommended to assess treatment efficacy and potential side effects, and the treatment choice should be reassessed in consultation with the patient's oncologist to ensure the biological therapy doesn't interfere with cancer surveillance or increase recurrence risk. Key considerations in managing this patient include:

• Avoiding TNF inhibitors due to their potential risks in patients with a history of malignancy
• Selecting a biological therapy with a favorable safety profile regarding malignancy risk
• Closely monitoring the patient for signs of treatment efficacy and potential side effects
• Collaborating with the patient's oncologist to ensure comprehensive care.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1. 3 Ankylosing Spondylitis XELJANZ/XELJANZ XR is indicated for the treatment of adult patients with active ankylosing spondylitis (AS) who have had an inadequate response or intolerance to one or more TNF blockers. The best biological therapy for a patient with ankylosing spondylitis, peripheral arthritis, and a history of renal cell carcinoma (RCC) 2 years ago, considering recent malignancy, cannot be determined from the provided drug label, as it does not explicitly address the use of tofacitinib in patients with a history of malignancy, such as RCC 2.

• Key considerations include the patient's history of RCC and the potential risks associated with biological therapies in patients with a history of malignancy.
• No conclusion can be drawn regarding the best biological therapy for this patient based on the provided information.

From the Research

Treatment Options for Ankylosing Spondylitis

• The treatment of ankylosing spondylitis (AS) has been limited in recent decades, but anti-tumor necrosis factor (anti-TNF) therapy has been shown to be highly effective in AS and psoriatic arthritis (PsA) 3.
• TNF blockers, such as infliximab and etanercept, are approved for the treatment of rheumatoid arthritis (RA) in Europe and the USA, and have been shown to be effective in AS and PsA 3, 4.
• The efficacy of anti-TNF therapy in AS has been demonstrated in several studies, with response rates of about 60% 4.

Considerations for Patients with a History of Malignancy

• There is limited information on the use of biologic therapies in patients with a history of malignancy, such as renal cell carcinoma (RCC) 3, 5, 6, 4, 7.
• However, it is generally recommended to exercise caution when using biologic therapies in patients with a history of malignancy, due to the potential risk of reactivation or worsening of the malignancy.

Alternative Treatment Options

• Novel biological agents blocking IL-23 or IL-17, such as secukinumab, have shown promise in the treatment of AS and peripheral spondyloarthritis 5, 6.
• Small molecules, such as apremilast and tofacitinib, are also being investigated as potential treatment options for AS and peripheral spondyloarthritis 6.

Treatment of Peripheral Arthritis

• TNF blockers have been shown to be effective in treating peripheral arthritis, enthesitis, and dactylitis, which are typical manifestations of peripheral spondyloarthritis 7.
• The treatment of peripheral arthritis should be individualized, taking into account the severity of symptoms and the presence of objective signs of inflammation.