New-Onset Inflammatory Bowel Diseases Among IL-17 inhibitors-Treated Patients: Results From The Case-Control MISSIL Study

EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update

OBJECTIVE

New modes of action and more data on the efficacy and safety of existing drugs in psoriatic arthritis (PsA) required an update of the EULAR 2019 recommendations for the pharmacological treatment of PsA.

METHODS

Following EULAR standardised operating procedures, the process included a systematic literature review and a consensus meeting of 36 international experts in April 2023. Levels of evidence and grades of recommendations were determined.

RESULTS

The updated recommendations comprise 7 overarching principles and 11 recommendations, and provide a treatment strategy for pharmacological therapies. Non-steroidal anti-inflammatory drugs should be used in monotherapy only for mild PsA and in the short term; oral glucocorticoids are not recommended. In patients with peripheral arthritis, rapid initiation of conventional synthetic disease-modifying antirheumatic drugs is recommended and methotrexate preferred. If the treatment target is not achieved with this strategy, a biological disease-modifying antirheumatic drug (bDMARD) should be initiated, without preference among modes of action. Relevant skin psoriasis should orient towards bDMARDs targeting interleukin (IL)-23p40, IL-23p19, IL-17A and IL-17A/F inhibitors. In case of predominant axial or entheseal disease, an algorithm is also proposed. Use of Janus kinase inhibitors is proposed primarily after bDMARD failure, taking relevant risk factors into account, or in case bDMARDs are not an appropriate choice. Inflammatory bowel disease and uveitis, if present, should influence drug choices, with monoclonal tumour necrosis factor inhibitors proposed. Drug switches and tapering in sustained remission are also addressed.

CONCLUSION

These updated recommendations integrate all currently available drugs in a practical and progressive approach, which will be helpful in the pharmacological management of PsA.

Advances in pharmacotherapies for axial spondyloarthritis

INTRODUCTION

Axial spondyloarthritis (axSpA) refers to an inflammatory rheumatic disease that mainly affects the axial skeleton and leads to progressive radiographic changes of the sacroiliac joints and spine. axSpA is currently subdivided into the radiographic (r-axSpA) and non-radiographic (nr-axSpA) form. Both forms are associated with musculoskeletal pain, restriction of spinal mobility, specific extra-musculoskeletal manifestations, and overall, altered quality of life. The therapeutic management of axSpA is currently well standardized.

AREAS COVERED

We reviewed available literature (by using PubMed search) on non-pharmacological and pharmacological treatment options that may be used in axSpA, including r-axSpA and nr-axSpA, as well as the role of non-steroidal anti-inflammatory drugs (NSAIDs), biological agents including TNFalpha (TNFi) and IL-17 (IL-17i) inhibitors. New treatment options such as Janus kinase inhibitors are also reviewed.

EXPERT OPINION

NSAIDs remain the mainstay of initial therapy, and subsequently, biological agents (TNFi and IL-17i) may be envisaged. Four TNFi are licensed for the treatment of both r-axSpA and nr-axSpA, while IL-17i are approved in each indication. The choice between a TNFi and an IL-17i is mainly guided by the presence of extra-articular manifestations. JAKi were more recently introduced for the treatment of r-axSpA, but their use is restricted to specific patients with a safe cardiovascular profile.

Therapeutic consequences in patients with both inflammatory rheumatic diseases and multiple sclerosis

Dealing with patients with both multiple sclerosis (MS) and inflammatory rheumatic disorders (IRDs) is not uncommon for a rheumatologist, as there is a statistical association between SpA and MS. As several CNS demyelinating events have been reported in patients treated with TNF inhibitor (TNFi), the pre-existing demyelinating disease was considered a contraindication for TNFi. However, this contraindication is mainly based on a randomized controlled trial in MS and not on large epidemiological studies. According to the last epidemiological studies, TNFi might not be an inducer of MS. Moreover, there are no clear recommendations on the use of the other DMARDs in patients suffering from an IRD and MS. In this review, we summarize the link between MS and IRDs and the impact of DMARDs on MS, especially TNFi. We also look at the impact of disease-modifying drugs for adults with MS and IRDs.

Secukinumab Loss of Efficacy Is Perfectly Counteracted by the Introduction of Combination Therapy (Rescue Therapy): Data from a Multicenter Real-Life Study in a Cohort of Italian Psoriatic Patients That Avoided Secukinumab Switching

Since psoriasis (PsO) is a chronic inflammatory disease, patients may experience a drug failure also with very effective drugs (i.e., secukinumab) and, consequently, dermatologists have two therapeutic options: switching or perform a combination therapy (rescue therapy) to save the drug that had decreased its efficacy. At the moment no studies focused on combination/rescue therapy of secukinumab, so we performed a 52-weeks multicenter retrospective observational study that involved 40 subjects with plaque psoriasis that experienced a secondary failure and were treated with combination therapy (ciclosporin (n = 11), MTX (n = 15), NB-UVB (n = 7) and apremilast (n = 7)). After 16 weeks of rescue/combination therapy, PASI and a DLQI varied respectively from 8 [7.0–9.0] and 13 [12.0–15.0], to 3 [2.8–4.0] and 3 [2.0–3.3]), suggesting a significant improvement of daily functionality and quality of life. Results were maintained at 52 weeks. No side effects were experienced during the study. Secukinumab remains a safety and effective drug for PsO patients also in the IL-23 and JAK inhibitors era. The rescue therapy is a valid therapeutic option in case of secukinumab secondary failure.