What are the alternatives to Otezla (apremilast) that my insurance will cover?

Alternatives to Otezla (Apremilast) for Psoriatic Arthritis

TNF inhibitor biologics are the recommended first-line alternative to Otezla for psoriatic arthritis due to their superior efficacy in treating both joint symptoms and skin manifestations. 1

First-Line Alternatives to Otezla

• TNF inhibitors (TNFi) such as adalimumab, etanercept, infliximab, golimumab, and certolizumab pegol are conditionally recommended over Otezla for treating psoriatic arthritis with better efficacy for joint symptoms 1, 2
• TNFi biologics are particularly beneficial for patients with moderate to severe psoriatic arthritis who need more effective control of both skin and joint symptoms 1
• For patients with predominantly joint disease, TNFi biologics should be the first choice when transitioning from Otezla 1, 2

Second-Line Alternatives to Otezla

• IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) are recommended as second-line alternatives, particularly for patients with severe psoriasis and joint involvement who have contraindications to TNF inhibitors 1, 2
• IL-12/23 inhibitors (ustekinumab, guselkumab) are recommended for patients with psoriatic arthritis who also have concomitant inflammatory bowel disease 1, 2
• JAK inhibitors such as tofacitinib are conditionally recommended over Otezla, especially for patients who prefer oral therapy 2, 1

Treatment Algorithm Based on Clinical Presentation

For Patients with Predominantly Joint Disease:

1. TNF inhibitors (first choice) 1, 2
2. IL-17 inhibitors 2
3. IL-12/23 inhibitors 2
4. JAK inhibitors (tofacitinib) 2

For Patients with Predominantly Skin Disease with Joint Involvement:

1. IL-17 inhibitors or IL-12/23 inhibitors 1, 2
2. TNF inhibitors 1
3. JAK inhibitors 1

Oral Medication Options

• Tofacitinib is conditionally recommended over Otezla for patients who prefer oral therapy 2
• Methotrexate and other oral small molecules (OSMs) like sulfasalazine and leflunomide may be considered if the patient prefers oral medication over injectable biologics 2
• Switching to another OSM may be considered if the patient has intolerable side effects with Otezla 2

Special Clinical Scenarios

• For patients with psoriatic arthritis and concomitant inflammatory bowel disease, IL-12/23 inhibitors are preferred 2, 1
• For patients with recurrent or serious infections, abatacept may be considered 2
• For patients with enthesitis, TNF inhibitors are conditionally recommended over Otezla 2
• For patients with axial disease/psoriatic spondylitis, TNF inhibitors or IL-17 inhibitors are recommended 2

Insurance Considerations

• TNF inhibitors generally have better insurance coverage due to their longer presence on the market and established efficacy 1
• Generic methotrexate is typically the most affordable and widely covered option by insurance plans 2
• Step therapy protocols often require trial of conventional DMARDs like methotrexate before covering biologics 2

Common Pitfalls to Avoid

• Failing to consider comorbidities when selecting alternatives (e.g., avoiding TNF inhibitors in patients with congestive heart failure or demyelinating disease) 2
• Not recognizing that combination therapy with methotrexate may improve efficacy of certain biologics, particularly infliximab and adalimumab 2
• Overlooking the potential for serious infections with biologics and JAK inhibitors, which requires appropriate screening and monitoring 1
• Failing to consider patient preferences regarding oral vs. injectable therapy, which can significantly impact adherence 2