Would previous use of TNF inhibitors affect the therapeutic effect of IL-17 or IL-12/23 inhibitors on psoriasis and psoriatic arthritis: results from a systematic review

Navigating Psoriatic Arthritis: Treatment Pathways and Patient-Specific Strategies for Improved Outcomes

Psoriatic arthritis (PsA) is a multifaceted chronic immune-mediated disease characterized by joint, skin, nail and entheseal involvement, affecting approximately 0.3-1% of the global population. In recent years, the treatment options for PsA have expanded from traditional nonsteroidal anti-inflammatory drugs and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to include biologic DMARDs and targeted synthetic DMARDs. Owing to the heterogeneity of the disease and prevalence of comorbidities, the selection and sequence of treatment are often unclear. In this narrative review, we outline the patient journey from diagnosis through various treatment lines, from conventional therapies to bDMARDS and tsDMARDs, and the considerations for treatment sequencing in patients who do not achieve an adequate response. We examine the factors influencing treatment response, such as disease severity, predominant disease domain, comorbidities, genetic variations, pharmacokinetic and immunogenicity issues. We highlight the importance of identifying robust biomarkers to predict response and the need to determine patient-specific factors, including the contribution of inflammatory mechanisms to disease activity, to inform treatment strategies and improve long-term outcomes. Promising results with more recently marketed biologic and targeted synthetic DMARDs, and the use of combination treatment approaches, offer new options for managing treatment-experienced patients.

Effect of Bimekizumab on Patient-Reported Outcomes and Work Productivity in Patients With Psoriatic Arthritis: 1-Year Results From 2 Phase III Studies

OBJECTIVE

To assess the longer-term effect of bimekizumab up to 1 year on patient-reported symptoms, health-related quality of life (HRQOL), and work productivity in patients with active PsA who were biologic disease-modifying antirheumatic drug (bDMARD)-naïve or had inadequate response/intolerance to tumor necrosis factor inhibitors (TNFi-IR).

METHODS

BE OPTIMAL (ClinicalTrials.gov: NCT03895203; bDMARD-naïve patients) and BE COMPLETE (NCT03896581; TNFi-IR patients) are phase III studies of subcutaneous bimekizumab 160 mg every 4 weeks. Both studies were double-blind and placebo-controlled to 16 weeks. Patients who completed week 52 of BE OPTIMAL or week 16 of BE COMPLETE were eligible for the open-label extension, BE VITAL (NCT04009499), during which all patients received bimekizumab. Patient-reported pain, fatigue, physical function, HRQOL, and work productivity are reported to week 52 or 40 (52/40) using individual study data for bimekizumab and placebo treatment arms.

RESULTS

Bimekizumab-randomized patients demonstrated sustained mean improvements from baseline in patient-reported outcomes to week 52/40, including pain (visual analog scale [0-100 mm]: bDMARD-naïve -30.5; TNFi-IR -31.8), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue scale [0-52]: bDMARD-naïve 5.3; TNFi-IR 6.0), physical function (Health Assessment Questionnaire-Disability Index [0-3]: bDMARD-naïve -0.34; TNFi-IR -0.39), and HRQOL (36-item Short Form Health Survey, physical component summary: bDMARD-naïve 8.1; TNFi-IR 8.4); placebo patients who switched to bimekizumab at week 16 demonstrated comparable levels of improvement from week 16 to week 52/40. Improvements in overall work impairment were sustained among bimekizumab-randomized patients to week 52. Similar trends were observed for absenteeism, presenteeism, and activity impairment.

CONCLUSION

Bimekizumab treatment resulted in sustained improvements in patient-reported symptoms, HRQOL, and work productivity up to 1 year in bDMARD-naïve and TNFi-IR patients with active PsA.

Sequential biologic therapy in the treatment of active psoriatic arthritis in China: a cost-effectiveness analysis

OBJECTIVE

Compared with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), biologics are more effective and are recommended to be included in the sequential treatment for psoriatic arthritis (PsA) patients. However, biologics are expensive and the cost-effectiveness of sequential biologic therapy in China remains unknown. The purpose of this study is to evaluate the cost-effectiveness of different sequential treatment option for PsA patients who have not responded to csDMARDs from the perspective of Chinese healthcare system.

METHODS

We constructed a discrete event simulation model to evaluate the cost-effectiveness of 7 monotherapy treatments and 32 sequential treatments. In sequential therapy, two different types of biologics were used as first-line and second-line treatments, respectively, with the best supportive care (BSC) as the third-line treatment. The primary outcomes included total treatment costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). One-way and probability sensitivity analyses were performed to explore the uncertainty of our model.

RESULTS

Compared to all other strategies, initiating with secukinumab followed by etanercept (SEC-ETN) provided the highest health benefits. At a willingness-to-pay (WTP) threshold of US $38,161 per QALY, SEC-ETN was the most cost-effective strategy, with an ICER of $20,837 per QALY. One-way sensitivity analysis and probabilistic sensitivity analysis results confirmed the robust of this conclusion.

CONCLUSIONS

In China, SEC-ETN may be the most cost-effective strategy for patients who have failed treatment with csDMARDs and have not previously used biologics. The results provide evidence for identifying the optimal biologic treatment strategy for PsA patients in China. Key Points • Compared with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), biologics are more effective and are recommended to be included in the sequential treatment for psoriatic arthritis (PsA) patients. However, the cost-effectiveness of sequential biologic therapy in China remains unclear. • At a willingness-to-pay threshold of $38,161, initiating with secukinumab followed by etanercept (SEC-ETN) was cost-effective strategy, outperforming other strategies. • From the perspective of the Chinese healthcare system, the optimal biologic treatment strategy was SEC-ETN in China.

Efficacy, drug survival, safety and metabolic parameters of ixekizumab in patients with moderate-to-severe psoriasis in China: A two-year real-world study

Long-term, real-world studies of the efficacy and metabolic parameters of ixekizumab in difficult-to-treat areas of psoriasis are lacking. A two-year retrospective study was conducted to evaluate the long-term efficacy, safety, drug survival and metabolic parameters of ixekizumab in the real world. A total of 258 patients were enrolled. At 52 weeks, PASI 75/90/100 was achieved in 92.0 %, 79.8 % and 54.6 % of patients, respectively. The efficacy was maintained at week 104 with PASI 75/90/100 of 92.6 %, 81.5 % and 48.1 %, respectively. At week 12, sPGA 0/1 was achieved in 71.0 % of scalp psoriasis, 60.0 % of palmoplantar psoriasis and 68.8 % of genital psoriasis. The probability of drug survival at 12 and 24 months was 67.1 % and 56.3 %, respectively. The most common adverse events included local injection reactions (31.8 %), allergies (11.6 %) and infections (6.1 %). No disease activation was observed in patients with latent tuberculosis or hepatitis B/C. No hyperlipidemia or hyperglycemia was observed. This study confirmed the long-term efficacy, high drug survival and favorable safety of ixekizumab in a real-world setting.

The immunologic role of IL-23 in psoriatic arthritis: a potential therapeutic target

INTRODUCTION

Psoriatic arthritis (PsA) is a debilitating chronic condition characterized by inflammation of the joints, bones, enthesis, and skin. The pivotal role of interleukin-23 (IL-23) in the pathogenesis of PsA has become increasingly evident. This proinflammatory cytokine is markedly elevated in patients with PsA, suggesting its potential as a therapeutic target. Consequently, IL-23 inhibitors have emerged as promising first-line biologic treatments for PsA.

AREAS COVERED

This review delves into the immunopathogenic mechanisms of IL-23 at the cellular and molecular levels in PsA. Furthermore, it provides the recent efficacy and safety profiles of IL-23 inhibitors. We conducted a literature search in PubMed for the following terms: 'IL-23 and psoriatic arthritis,' 'Ustekinumab,' 'Guselkumab,' 'Risankizumab,' and 'Tildrakizumab.' In addition, we retrieved clinical trials involving IL-23 inhibitors registered in ClinicalTrials.gov, EudraCT, and ICTRP.

EXPERT OPINION

Despite the promising outcomes observed with IL-23 inhibitors, several challenges persist. The long-term effects of these agents require further investigation through prospective studies, and their limited accessibility worldwide necessitates urgent attention. Additionally, ongoing research is warranted to explore other potential drug targets within the IL-23/IL-23 R axis. The development of reliable biomarkers could greatly enhance early detection, tailored management strategies, and personalized treatment approaches for patients with PsA.

Bimekizumab in patients with active psoriatic arthritis and previous inadequate response or intolerance to tumour necrosis factor-α inhibitors: a randomised, double-blind, placebo-controlled, phase 3 trial (BE COMPLETE)

BACKGROUND

Bimekizumab is a monoclonal IgG1 antibody that selectively inhibits interleukin (IL)-17F and IL-17A. This study compared the efficacy and safety of bimekizumab with placebo over 16 weeks in patients with active psoriatic arthritis and previous inadequate response or intolerance to tumour necrosis factor-α (TNFα) inhibitors.

METHODS

BE COMPLETE was a phase 3, multicentre, randomised, double-blind, placebo-controlled trial conducted across 92 sites (including hospitals, clinics, and research centres) in 11 countries (Australia, Canada, Czech Republic, Germany, Hungary, Italy, Japan, Poland, Russia, the UK, and the USA). Eligible patients were aged 18 years or older with adult-onset psoriatic arthritis (meeting the Classification Criteria for Psoriatic Arthritis for at least 6 months before screening) with a history of inadequate response or intolerance to treatment with one or two TNFα inhibitors for either psoriatic arthritis or psoriasis. We stratified patients with active psoriatic arthritis by region and previous TNFα inhibitor use. Patients were randomly assigned (2:1) to receive subcutaneous bimekizumab 160 mg every 4 weeks or placebo by an interactive-voice and web-response system on the basis of a predetermined randomisation schedule. The primary endpoint was the proportion of patients with 50% or greater improvement in American College of Rheumatology criteria (ACR50) at week 16 (non-responder imputation). Efficacy analyses were done in the randomised population. The safety analysis set comprised patients who received one or more doses of study treatment. This trial was registered at ClinicalTrials.gov, NCT03896581, and is completed.

FINDINGS

Between March 28, 2019, and Feb 14, 2022, 556 patients were screened and 400 patients were randomly assigned to bimekizumab 160 mg every 4 weeks (n=267) or placebo (n=133). The primary and all hierarchical secondary endpoints were met at week 16. 116 (43%) of 267 patients receiving bimekizumab reached ACR50, compared with nine (7%) of 133 patients receiving placebo (adjusted odds ratio [OR] 11·1 [95% CI 5·4-23·0], p<0·0001). 121 (69%) of 176 patients with psoriasis affecting at least 3% body surface area at baseline who received bimekizumab reached 90% or greater improvement in the Psoriasis Area and Severity Index (PASI90), compared with six (7%) of 88 patients who received placebo (adjusted OR 30·2 [12·4-73·9], p<0·0001). Treatment-emergent adverse events up to week 16 were reported in 108 (40%) of 267 patients receiving bimekizumab and 44 (33%) of 132 patients receiving placebo. There were no new safety signals and no deaths.

INTERPRETATION

Bimekizumab treatment led to superior improvements in joint and skin efficacy outcomes at week 16 compared with placebo in patients with psoriatic arthritis and inadequate response or intolerance to TNFα inhibitors. The safety profile of bimekizumab was consistent with previous phase 3 studies in patients with plaque psoriasis, and studies of IL-17A inhibitors.

FUNDING

UCB Pharma.