Biological and targeted-synthetic disease-modifying antirheumatic drugs for peripheral psoriatic arthritis
Several classes of biological disease-modifying antirheumatic drugs (bDMARDs) have been demonstrated to be effective treatments for psoriatic arthritis. These include tumour necrosis factor (TNF) inhibitors, interleukin-17a (IL-17a) antagonists, interleukin-12 and -23 (IL-12 and -23) antagonists, and interleukin-23 (IL-23) antagonists. All are effective in the treatment of psoriatic arthritis and psoriatic skin disease, although there are subtle differences in the relative effectiveness that may influence the individual’s drug preference. These drugs are used by specialists for psoriatic arthritis when csDMARDs are not effective or are poorly tolerated.
The bDMARDs within each drug class are generally considered to be equally effective in peripheral psoriatic arthritis and drug choice is influenced by patient preference regarding route of administration and dosing frequency. For people with psoriatic arthritis and comorbid inflammatory bowel disease, TNF inhibitors other than etanercept may be preferred because etanercept has been shown to be ineffective in the management of inflammatory bowel disease. Similarly, IL-17a antagonists are often avoided in people with inflammatory bowel disease.
Targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) that inhibit the Janus kinase (JAK) pathway have also been demonstrated to be effective treatments for psoriatic arthritis.
The usual dosages of the b/tsDMARDs that are listed on the Pharmaceutical Benefits Scheme (PBS) for psoriatic arthritis (in alphabetical order) are:
adalimumab 40 mg subcutaneously, every 2 weeks adalimumab adalimumab adalimumab
OR
bimekizumab 160 mg subcutaneously, every 4 weeks bimekizumab bimekizumab bimekizumab
OR
certolizumab pegol 400 mg subcutaneously, as a single dose at 0, 2 and 4 weeks, then 200 mg subcutaneously, every 2 weeks thereafter certolizumab pegol certolizumab pegol certolizumab pegol
OR
certolizumab pegol 400 mg subcutaneously, as a single dose at 0, 2 and 4 weeks, and thereafter every 4 weeks certolizumab pegol certolizumab pegol certolizumab pegol
OR
etanercept 50 mg subcutaneously, once weekly1 etanercept etanercept etanercept
OR
golimumab 50 mg subcutaneously, every 4 weeks golimumab golimumab golimumab
OR
guselkumab 100 mg subcutaneously, as a single dose at 0 and 4 weeks, and thereafter every 8 weeks guselkumab guselkumab guselkumab
OR
infliximab 5 mg/kg intravenously, as a single dose at 0, 2 and 6 weeks, and thereafter every 8 weeks infliximab infliximab infliximab
OR
ixekizumab 160 mg subcutaneously, as a single dose, then 80 mg subcutaneously, every 4 weeks thereafter ixekizumab ixekizumab ixekizumab
OR
secukinumab 150 mg subcutaneously, as a single dose at 0, 1, 2, 3 and 4 weeks, and thereafter every 4 weeks2 secukinumab secukinumab secukinumab
OR
tofacitinib 5 mg orally, twice daily tofacitinib tofacitinib tofacitinib
OR
upadacitinib 15 mg orally, daily upadacitinib upadacitinib upadacitinib
OR
ustekinumab 45 mg subcutaneously, as a single dose at 0 and 4 weeks, and thereafter every 12 weeks3. ustekinumab ustekinumab ustekinumab
The specialist will determine the appropriate approach to monitoring, screening for infection, and vaccination based on the adverse effect profile of the drug used and patient factors (eg disease activity, comorbidities). See Principles of immunomodulatory drug use for more detailed information.
Dose reduction is not currently recommended in this group, and if being considered by the patient, should involve a conversation with their rheumatologist. See An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis for further advice.