Alternative Treatments to Bimekizumab for Psoriatic Arthritis
If bimekizumab (Bimzelx) is not covered by insurance, TNF inhibitors should be your first-line alternative, as they remain the preferred initial biologic therapy for PsA according to ACR/NPF guidelines, with other IL-17 inhibitors like secukinumab or ixekizumab serving as comparable mechanistic alternatives. 1
First-Tier Alternatives: TNF Inhibitors
TNF inhibitors are conditionally recommended as the preferred first biologic choice for active PsA and include: 1
- Adalimumab (Humira) - 40 mg every 2 weeks subcutaneously 2
- Etanercept (Enbrel) - 50 mg weekly subcutaneously 3
- Infliximab (Remicade) - IV infusion dosing 3
- Golimumab (Simponi) - 50 mg monthly subcutaneously 3
- Certolizumab (Cimzia) - 200-400 mg dosing 3
These agents have the most extensive long-term safety data and proven efficacy in slowing radiographic progression of joint disease. 3
Second-Tier Alternatives: Other IL-17 Inhibitors (Most Similar to Bimekizumab)
Since bimekizumab is an IL-17A/F inhibitor, the most mechanistically comparable alternatives are other IL-17 pathway inhibitors: 4, 2
- Secukinumab (Cosentyx) - 150 mg or 300 mg subcutaneously, conditionally recommended over IL-12/23 inhibitors for patients with severe psoriasis 1, 5
- Ixekizumab (Taltz) - IL-17A inhibitor with similar mechanism 3
Note: Bimekizumab demonstrated superior ACR70 response compared to secukinumab 150 mg and 300 mg at 52 weeks in head-to-head comparisons, but secukinumab remains an effective alternative when bimekizumab is unavailable. 5
Third-Tier Alternatives: IL-12/23 Inhibitors
- Ustekinumab (Stelara) - targets IL-12/23 pathway, conditionally recommended especially if patient prefers less frequent dosing (every 12 weeks after loading) 1
- Particularly useful if patient has concomitant inflammatory bowel disease 1
Fourth-Tier Alternatives: Non-Biologic Options
Oral targeted synthetic DMARDs for patients who prefer oral therapy or have contraindications to biologics: 1
- Tofacitinib (Xeljanz) - JAK inhibitor, conditionally recommended over apremilast 1, 3
- Apremilast (Otezol) - phosphodiesterase-4 inhibitor, less effective than biologics but safer in patients with recurrent infections 1, 3
Fifth-Tier Alternative: T-Cell Costimulation Modulator
- Abatacept (Orencia) - conditionally recommended particularly for patients with recurrent serious infections where TNF inhibitors may be contraindicated 1, 6
Treatment Selection Algorithm Based on Patient Characteristics
If patient has severe psoriasis (≥3% body surface area): Prioritize IL-17 inhibitors (secukinumab, ixekizumab) or IL-12/23 inhibitors (ustekinumab) over TNF inhibitors 1
If patient has concomitant inflammatory bowel disease: Avoid IL-17 inhibitors; use ustekinumab (IL-12/23 inhibitor) or TNF inhibitors instead 1, 7
If patient has recurrent or serious infections: Consider abatacept over TNF inhibitors; avoid tofacitinib if recurrent candida infections 1, 6
If patient has contraindications to TNF inhibitors (congestive heart failure, demyelinating disease, recurrent infections): Use IL-17 inhibitors, IL-12/23 inhibitors, abatacept, or tofacitinib 1
If patient prefers oral medication: Use tofacitinib over apremilast (more effective), or apremilast if biologics are inappropriate 1, 3
If patient prefers less frequent dosing: Ustekinumab (every 12 weeks) is preferred 1
Critical Insurance Coverage Considerations
Most insurance formularies cover TNF inhibitors as first-line biologics before approving IL-17 or IL-12/23 inhibitors, which aligns with guideline recommendations. 1 You may need to demonstrate inadequate response to at least one TNF inhibitor before insurance will approve secukinumab or other IL-17 inhibitors as step-therapy alternatives to bimekizumab.
Important Safety Caveat
Never combine two biologic agents simultaneously - the ACR/NPF guidelines explicitly recommend switching between biologics rather than combining them due to unpredictable immune dysregulation and lack of safety data. 6