The European Alliance of Associations for Rheumatology (EULAR) recommends a treat-to-target approach for psoriatic arthritis (PsA), suggesting more intensive therapy for patients with poor prognostic factors based on their disease presentation. The goal is to achieve remission or, alternatively, low disease activity by regularly assessing disease activity and adjusting treatment as necessary.
Recent studies have indicated no significant advantage of early biologic treatments over standard methotrexate therapy for PsA. However, these studies did not focus on patients with poor prognostic factors. This gap in research led to the SPEED trial, funded by the National Institute for Health Research (NIHR), which aimed to compare disease activity in 192 PsA patients with poor prognostic factors. These patients were treated with one of three regimens: standard step-up care with conventional disease-modifying anti-rheumatic drugs (csDMARD), combination csDMARD, or early induction with a tumor necrosis factor inhibitor (TNFi). The primary outcome was the mean PsA disease activity score (PASDAS) at 24 weeks. The data were presented at the 2025 annual EULAR congress in Barcelona.
By Week 24, the results revealed differences in PASDAS scores between the treatment groups. Both the combination csDMARD and early TNFi groups showed better outcomes compared to the standard step-up care group. Notably, no significant difference was found between the early TNFi and combination csDMARD groups. However, by Week 48, only the early TNFi group maintained a benefit compared to standard step-up care.
Laura Coates, presenting the findings, emphasized that early intensive therapy with biologics or combination csDMARDs offers superior control for early moderate-to-severe PsA. “Even with just six months of early biologic therapy, better outcomes are maintained at one year for those initially treated with a TNF inhibitor,” she explained.
Another study presented at the congress explored the safety and effectiveness of combining biologic and targeted synthetic DMARD therapy in PsA patients. Researchers from the University of Toronto analyzed data from 22 patients in their psoriatic arthritis cohort, who were treated with combinations of biologic DMARDs (bDMARDs) and either Janus kinase inhibitors (JAKi) or TYK2 inhibitors (TYK2i). The primary reasons for combination therapy were active peripheral arthritis and skin conditions, including palmoplantar psoriasis.
The results showed improvement in disease activity across multiple measures. In the bDMARD plus JAKi group, the most common combination was IL-17 inhibitors (IL-17i) and JAKi. Over 10.5 patient-years of exposure, only one case of mild infectious stomatitis was reported, which did not result in treatment discontinuation. Similarly, the IL-23 inhibitors (IL-23i) plus JAKi were used for 3.7 patient-years with no safety events.
In the bDMARD plus TYK2i group, IL-17i plus TYK2i were used for 8.5 patient-years, with one patient experiencing two mild upper respiratory infections (URI) while on bimekizumab plus deucravacitinib. This led to a switch to risankizumab plus deucravacitinib. For IL-23i plus TYK2i, used for 8.3 patient-years, two cases of mild URI were reported, prompting a switch to bimekizumab monotherapy in both cases. Additionally, there was one case of folliculitis, where therapy continued without interruption. No adverse events were reported in a patient who received TNFi plus TYK2i for 0.9 patient-years.
The study also included bDMARD and apremilast combinations, where two cases of diarrhea were observed, but no infections were reported.
Overall, the study found that combinations of bDMARDs with JAKi, TYK2i, and apremilast demonstrated a favorable safety profile. All infections were mild, managed without hospitalization, and rarely led to treatment discontinuation. Additionally, patients showed short-term improvements in both musculoskeletal and skin symptoms. However, given that this was an observational study with short-term follow-up, further randomized clinical trials are needed to validate these findings.
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