Background/Purpose: Progression of psoriatic arthritis (PsA) can lead to irreversible joint damage and functional impairment. TNF inhibitors (TNFi’s) have been shown to improve signs and symptoms of PsA and, in contrast to apremilast, a phosphodiesterase-4 inhibitor, inhibit radiographic progression. The clinical impact of using apremilast prior to a TNFi is not fully understood. This study evaluated clinical responses associated with timely vs delayed use of TNFi’s among patients with PsA.

Methods: A Markov model was developed to evaluate improvements in joint and skin symptoms in patients with moderate-to-severely active PsA (≥3 swollen joints and ≥3 tender joints) treated with TNFi’s (adalimumab, etanercept, infliximab, or golimumab) and/or apremilast over a 1-year time horizon. In the model, PsA patients received either TNFi (timely use) or apremilast (delayed use) as initial treatment. Those who did not achieve ACR20 responses in the first 12 weeks of treatment or lost responses in the subsequent weeks either switched to a different TNFi (after timely use of first TNFi) or initiated a first TNFi (representing delayed use). Subsequent non-responses or loss of responses were followed by palliative care (both arms). Joint responses (achievement of ACR20 responses) were evaluated for all patients; skin responses (defined by 75% improvement in Psoriasis Area and Severity Index score [PASI75]) were evaluated in a subgroup of patients with moderate-to-severe psoriasis (affected body surface area [BSA] ≥3%). Efficacy inputs and distributions of patients treated with anti-TNFs were based on randomized controlled trials and market share data, respectively. Certolizumab, which was only recently approved, was excluded. Outcomes included ACR20/PASI75 response rates at year 1, mean time with ACR20/PASI75 responses, and number needed to treat (NNT) with timely vs. delayed TNFi use for achievement of ACR20/PASI75 responses in 1 patient.

Results: After one year, patients who initiated a TNFi had higher ACR20 response rates, more prolonged times as ACR20 responders and lower NNTs (Table) vs those initiating apremilast. Results were similar in the subgroup of patients with comorbid moderate-to-severe psoriasis: those who initiated a TNFi vs apremilast had higher combined ACR20/PASI75 response rates, more time as combined ACR20/PASI75 responders, and lower NNTs for combined responses.

Conclusion: Based on this modeling approach, timely use of TNFi’s was a more effective strategy for management of PsA compared with delayed use of TNFi’s due to sustained improvements in both joint and skin symptoms.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/impact-of-timely-versus-delayed-use-of-anti-tumor-necrosis-factor-tnf-biologics-in-the-treatment-of-psoriatic-arthritis-results-from-a-modeling-study/