Every major drug therapy for psoriatic arthritis (PsA) -- with one notable exception -- was shown to be effective in treating skin disease in this population, according to a review published in The Journal of Rheumatology.
The data will inform upcoming treatment guidance from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
The systematic review ultimately included 37 studies. Phosphodiesterase 4 inhibitors (PDE4i), Janus kinase inhibitors (JAKi), tyrosine kinase 2 inhibitors (TYK2i), interleukin-17 inhibitors (IL-17i), IL-12/23i, IL-23i, and tumor necrosis factor inhibitors (TNFi) all were found to have high-quality data supporting their efficacy in treating plaque psoriasis when compared with placebo. Head-to-head studies with high-quality data supported IL-17i and IL-23i agents over TNFi agents.
CTLA4-Ig, also known as abatacept (Orencia), was not recommended for cutaneous psoriasis in patients with PsA.
Kristina Callis Duffin, MD, MS, chair of the department of dermatology at the University of Utah School of Medicine, served as first author for the review. She recently discussed the review and its findings with the Reading Room. The exchange has been edited for length and clarity.
What were the impetus and specific objectives for this review?
Duffin: Over the last several years, many new therapeutic agents have been developed to treat skin and nail psoriasis. Some have new data for PsA domains, such as peripheral and axial arthritis, enthesitis, and dactylitis. There are always questions about which therapies work best across different psoriatic disease domains.
The objective of the skin domain group was to systematically review the literature from 2013 to 2021 and assess efficacy of treatments for cutaneous psoriasis in patients with PsA. These data were used to inform the main GRAPPA treatment recommendations update.
The goal was to provide recommendations based on the quality of the data supporting use of these therapeutic agents, and not create guidelines. We are not telling physicians they have to start with a certain agent and then follow it with this one. We just wanted to help clinicians make more informed decisions for themselves and their patients.
What were the review's key findings?
Duffin: Overall, our review and recommendations support the use of PDE4i, JAKi/TYK2i, TNFi, IL-12/23i, IL-23i, and IL-17i for cutaneous psoriasis in patients with PsA.
Most systemic therapeutic agents we use primarily for PsA have good quality data supporting their use in skin disease, with the exception of abatacept for which skin data are poor. In other words, if patients with PsA have significant skin psoriasis, abatacept would not be the best choice.
Do you have any specific suggestions for clinicians based on the review and its findings?
Duffin: Our findings are in line with the psoriasis literature showing that IL-12/23 and IL-23 inhibitors work well for patients with skin disease. However, the main GRAPPA treatment recommendations publication show that IL-12/23 and IL-23 inhibitors do not have quality evidence supporting efficacy in axial PsA. If a patient has skin disease and significant axial disease, TNF-alpha and IL-17 inhibitors have better efficacy.
Clinicians addressing skin disease should consider many variables -- including extent, morphology, location, failure of other therapies, comorbidities, clinical judgment, patient preference, availability, administration, cost, and other factors -- to select the appropriate therapy for the skin. Ideally, this decision-making occurs as a collaborative, interdisciplinary process between dermatologists, rheumatologists, the patient, and other specialists.
Duffin reported financial relationships with Amgen, AbbVie, Celgene, Eli Lilly, Janssen, BMS, Stiefel, Novartis, Pfizer, Sienna, UCB, Regeneron, Boehringer Ingeheim, and Ortho Dermatologic.
Primary Source
The Journal of Rheumatology