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

Alternatives to Otezla (Apremilast) for Psoriasis and Psoriatic Arthritis

For patients who cannot use or have failed Otezla (apremilast), TNF inhibitor biologics are the recommended first-line alternative due to their superior efficacy in treating both psoriatic arthritis and psoriasis. 1

First-Line Alternatives to Otezla

TNF Inhibitor Biologics

• TNF inhibitors are conditionally recommended over Otezla for treating psoriatic arthritis with better efficacy for joint symptoms 1
• Options include:
  • Adalimumab (Humira): 40mg subcutaneously every other week 1, 2
  • Etanercept (Enbrel): 50mg subcutaneously once weekly 1, 3
  • Infliximab: 5mg/kg IV infusion at weeks 0,2,6 and then every 6-8 weeks 1, 4

When to Consider TNF Inhibitors Over Otezla

• For patients with moderate to severe joint involvement 1
• For patients who have failed Otezla therapy 1
• For patients with enthesitis (inflammation where tendons/ligaments attach to bone) 1
• For patients with axial disease/spondylitis (TNF inhibitors strongly preferred) 1

Second-Line Alternatives to Otezla

IL-17 Inhibitors

• Recommended when patients have:
  • Severe psoriasis with joint involvement 1
  • Contraindications to TNF inhibitors (heart failure, recurrent infections, demyelinating disease) 1
• Not recommended for patients with inflammatory bowel disease 1

IL-12/23 Inhibitors

• Consider when patients have:
  • Severe psoriasis with joint involvement 1
  • Concomitant inflammatory bowel disease 1
  • Preference for less frequent drug administration 1
• Ustekinumab can be combined with methotrexate for enhanced efficacy 1

JAK Inhibitors

• Tofacitinib is conditionally recommended over Otezla for enthesitis 1
• Provides an oral alternative when patients prefer to avoid injections 1
• Consider for patients with recurrent infections who prefer oral therapy 1

Treatment Algorithm Based on Clinical Presentation

For Predominantly Joint Disease

1. First choice: TNF inhibitors (adalimumab, etanercept, infliximab) 1
2. Second choice: IL-17 inhibitors 1
3. Third choice: IL-12/23 inhibitors 1
4. Fourth choice: JAK inhibitors (tofacitinib) 1

For Predominantly Skin Disease with Joint Involvement

1. First choice: IL-17 inhibitors or IL-12/23 inhibitors (superior efficacy for skin) 1
2. Second choice: TNF inhibitors 1
3. Third choice: JAK inhibitors 1

For Enthesitis

1. First choice: TNF inhibitors 1
2. Second choice: IL-17 inhibitors 1
3. Third choice: IL-12/23 inhibitors 1
4. Fourth choice: JAK inhibitors 1

For Axial Disease/Spondylitis

1. First choice: TNF inhibitors (only proven effective option) 1
2. Second choice: IL-17 inhibitors 1
3. Avoid: IL-12/23 inhibitors (trials in axial disease were stopped due to lack of efficacy) 1

Common Pitfalls and Considerations

• Failure to screen for tuberculosis: Always test for latent TB before starting TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors 3, 2
• Ignoring comorbidities:
  • Avoid TNF inhibitors in patients with heart failure, demyelinating disease, or recurrent infections 1
  • Avoid IL-17 inhibitors in patients with inflammatory bowel disease 1
• Overlooking combination therapy: Consider combining biologics with methotrexate to enhance efficacy, especially for TNF inhibitors 1
• Inadequate monitoring: Regular monitoring for infections and other adverse effects is essential with all biologic therapies 3, 2
• Not considering patient preferences: Oral options (JAK inhibitors) may be preferred by patients who want to avoid injections 1

Safety Considerations

• TNF inhibitors carry increased risk of serious infections and potential risk of malignancies 3, 2
• IL-17 inhibitors may increase risk of Candida infections 1
• JAK inhibitors require monitoring for infections and potential cardiovascular effects 1
• Combination therapy with multiple immunosuppressants increases infection risk 5