Is this medication/surgery medically indicated for a patient with a history of recurrent infections on current medication?

Medical Indication for Treatment in Patients with Recurrent Infections

For patients with psoriatic arthritis and a history of recurrent infections, TNF inhibitors are generally contraindicated, and alternative biologics—specifically IL-12/23 inhibitors (such as ustekinumab or risankizumab), abatacept, or JAK inhibitors (such as tofacitinib)—should be prioritized instead. 1

Treatment Algorithm for Psoriatic Arthritis with Recurrent Infections

First-Line Biologic Selection

When selecting initial biologic therapy for a patient with active psoriatic arthritis and recurrent infections:

• Avoid TNF inhibitors as they are explicitly listed as contraindicated in patients with recurrent infections due to increased risk of serious infections 1

• Consider IL-12/23 inhibitors (ustekinumab, risankizumab) as the preferred first choice, particularly if the patient also has severe psoriasis, as these agents have no specific contraindications related to recurrent infections and offer less frequent dosing 1

• IL-17 inhibitors may be considered but should be avoided if the patient has a history of recurrent Candida infections specifically, as IL-17 inhibitors increase risk of mucocutaneous candidiasis 1, 2

• Abatacept is specifically recommended for patients with recurrent or serious infections as an alternative to TNF inhibitors, IL-17 inhibitors, and IL-12/23 inhibitors 1

• Tofacitinib (JAK inhibitor) can be used if the patient prefers oral medication or has recurrent Candida infections (making it preferable to IL-17 inhibitors), though monitoring for infections is required 1, 3

If Patient Fails Oral Small Molecules (OSM)

For patients with active psoriatic arthritis despite treatment with oral small molecules who have recurrent infections:

• Switch to IL-12/23 inhibitor over TNF inhibitor given the contraindication to TNF inhibitors 1

• Switch to abatacept over TNF inhibitor or IL-17 inhibitor if recurrent serious infections are the primary concern 1

• Switch to tofacitinib over TNF inhibitor if patient prefers oral therapy and does not have recurrent Candida infections 1

If Patient Fails IL-17 Inhibitor

For patients who have failed an IL-17 inhibitor (such as due to Candida infections):

• Switch to IL-12/23 inhibitor (risankizumab/Skyrizi) as this class does not carry the same Candida infection risk and has no cardiovascular contraindications 2

• Avoid switching to TNF inhibitor if recurrent infections remain a concern 1

• Consider abatacept as it is specifically recommended for patients with recurrent or serious infections 1

Critical Safety Considerations

Common pitfalls to avoid:

• Do not use TNF inhibitors in patients with documented recurrent infections, as this is an explicit contraindication across all major guidelines 1

• Do not use IL-17 inhibitors if the patient has a history of recurrent Candida infections specifically 1, 2

• When using abatacept in patients with hypogammaglobulinemia and recurrent severe infections, consider immunoglobulin supplementation at replacement doses (400-800 mg/kg/month) in collaboration with an allergist/immunologist 1

• Monitor all biologic-treated patients for new or worsening infections, and hold medication during acute illness 4

Concomitant Therapy

• Methotrexate combination therapy may be considered if the patient has severe skin manifestations or partial response to current therapy, though biologic monotherapy is generally preferred 1

• Topical corticosteroids can be safely used alongside any of these biologics without drug interaction concerns 2

• Avoid trimethoprim/sulfamethoxazole at high doses (800 mg/160 mg twice daily) if using methotrexate due to drug interaction, though Pneumocystis prophylaxis dosing is generally tolerated 1

Treatment Response Assessment

• Allow a full 3-month trial to properly assess biologic efficacy before declaring treatment failure 2

• Document objective measures at each visit including joint counts, skin assessment, functional status, and inflammatory markers to demonstrate treatment response 4

• Switch to alternative biologic class if inadequate response after 3 months, prioritizing agents without contraindications related to recurrent infections 2