What are the alternatives to Otezla (apremilast) for treating psoriasis or psoriatic arthritis?

Alternatives to Otezla (Apremilast) for Psoriasis and Psoriatic Arthritis

For patients requiring alternatives to Otezla (apremilast), TNF inhibitors are the recommended first-line biologic option for psoriatic arthritis, while IL-17 inhibitors are preferred for patients with more severe skin manifestations. 1, 2

First-Line Biologic Alternatives

TNF Inhibitors

• Etanercept (Enbrel) - 50mg weekly subcutaneous injection 3
• Adalimumab (Humira) - 40mg every other week subcutaneous injection 4
• Golimumab (Simponi) - Recommended by guidelines for patients who have failed other therapies 2
• Infliximab - Particularly effective when combined with methotrexate for severe manifestations 1

IL-17 Inhibitors

• Preferred over TNF inhibitors when:
  • Patient has severe skin manifestations
  • Patient has contraindications to TNF inhibitors (recurrent infections, congestive heart failure, demyelinating disease) 1

IL-12/23 Inhibitors

• Consider when:
  • Patient has concomitant inflammatory bowel disease
  • Patient prefers less frequent drug administration 1
  • Patient has contraindications to TNF inhibitors 1

Non-Biologic Alternatives

Oral Small Molecule (OSM) Therapies

• Methotrexate - Can be used alone or in combination with biologics 1
• Leflunomide - Alternative DMARD that can be used alone or with biologics 2
• Tofacitinib - Consider when patient prefers oral therapy 1
• Sulfasalazine/Cyclosporine - Alternative conventional DMARDs

Other Therapies

• Abatacept - Consider in patients with recurrent or serious infections 1
• NSAIDs - For symptom management, particularly for enthesitis 1

Treatment Algorithm Based on Clinical Scenario

For Patients with Predominantly Joint Symptoms

1. First choice: TNF inhibitor (etanercept, adalimumab, golimumab) 1, 2
2. If TNF inhibitor fails: Switch to different TNF inhibitor or IL-17 inhibitor 1
3. If second biologic fails: Consider IL-12/23 inhibitor or abatacept 1

For Patients with Severe Skin Manifestations

1. First choice: IL-17 inhibitor 1
2. If IL-17 inhibitor fails: TNF inhibitor or IL-12/23 inhibitor 1
3. If second biologic fails: Different class of biologic or combination therapy 5

For Patients with Enthesitis

1. First choice: NSAIDs 1
2. If NSAIDs fail: TNF inhibitor 1
3. If TNF inhibitor fails: IL-17 inhibitor or IL-12/23 inhibitor 1

Special Considerations

Combination Therapy

• In treatment-resistant cases, combination of a biologic with another agent may be considered
• Limited evidence supports combining apremilast with biologics for recalcitrant cases 5, 6, 7
• Adding methotrexate to TNF inhibitors (particularly infliximab or adalimumab) may be beneficial in patients with:
  • Severe skin manifestations
  • Partial response to current therapy
  • Concomitant uveitis 1

Comorbidities

• Inflammatory bowel disease: Prefer IL-12/23 inhibitors or TNF inhibitors 1
• Recurrent infections: Consider abatacept 1
• Recurrent candida infections: Consider tofacitinib over IL-17 inhibitors 1
• Cardiovascular disease: Use caution with TNF inhibitors in heart failure 4

Monitoring and Treatment Goals

• Implement a treat-to-target strategy aiming for minimal disease activity 1
• Regularly assess joint involvement, dactylitis, enthesitis, and skin manifestations 2
• Monitor for adverse effects specific to each medication class

Common Pitfalls to Avoid

• Failing to screen for tuberculosis before initiating TNF inhibitors 3, 4
• Not addressing comorbidities that may influence treatment selection
• Continuing ineffective therapy without appropriate switching strategies
• Overlooking the potential for combination therapy in resistant cases