Effectiveness of Sequential Lines of Biologic and Targeted Small Molecule Drugs in Psoriatic Arthritis: A Systematic Review

Rheumatology (Oxford). 2024 Jan 18:keae006. doi: 10.1093/rheumatology/keae006. Online ahead of print.


Objective: To assess current evidence for effectiveness of sequential lines of biologic and targeted small molecule disease modifying anti-rheumatic drugs (b/tsDMARDs) when used beyond first-line for psoriatic arthritis (PsA).

Methods: A systematic search of the literature (Medline, Embase, bibliographic searches) was undertaken (October and December 2022) to find studies meeting the criteria of assessing effectiveness of b/tsDMARDs beyond first-line in adults with PsA (PROSPERO CRD42022365298). Risk of bias assessment was undertaken (ROBINS-I/Cochrane RoB2).

Results: Of 2666 abstracts identified and following a full text review of 177 psoriatic disease studies, 12 manuscripts and two abstracts were eligible.Of the 12 manuscripts, 11 were observational and one was a sub-analysis of a RCT (n = 16 081: average age 49.5 years, female 53.3%). Two abstracts (n = 7186) were included. All studies comparing first- and second- line (3 studies) found a reduced response in second-line. On average, DAPSA remission (most reported outcome, 8 studies) was achieved in 26%, 19% and 10% first-, second- and third- line TNFi, and 22%, 13% and 11% first-, second- and third- line other bDMARDs respectively. Responses varied to third-line bDMARDs; four studies found comparable second- and third- line responses, five studies found diminishing responses in sequential lines.

Conclusion: Predominantly observational studies, inherently at high risk of bias, indicate bDMARDs can be effective to third-line in PsA, but that response is reduced after first line. There is very limited data for more advanced lines of b/tsDMARD. Prospective studies are required to better understand clinical response to advanced lines of treatment in PsA.

Keywords: bdmard; biological therapies; psoriatic arthritis; sequential line; systematic review.