Which Is the Best Option for AxSpA Patients After First TNFi Failure: Switch to Secukinumab or Cycling With Other TNFi?

Int J Rheum Dis. 2025 Apr;28(4):e70212. doi: 10.1111/1756-185X.70212.

Abstract

Objectives: Evaluation of drug survival and predictive factors of alternative tumor necrosis factor inhibitor (TNFi) and secukinumab (SEC) use after TNFi therapy in patients with axial spondyloarthritis (axSpA).

Methods: This was an observational retrospective study of axSpA patients who switched to second-line biological disease modifying antirheumatic drugs (bDMARD) between January 2018 and February 2023. Drug retention rate was evaluated using Kaplan-Meier analysis and log-rank test. Factors associated with drug survival of the second bDMARD were analyzed by multivariate regression analyses.

Results: A total of 201 axSpA patients (alternative TNFi: 143 patients, SEC: 58 patients) with a mean age 37.1 ± 8.6 years and consist of 58.2% male were included. Clinical characteristics and laboratory results at switching were comparable between groups. During a median follow-up period of 22.3 months, 80 (39.8%) of 201 patients discontinued bDMARD. Median follow-up period, drug discontinuation frequency, and drug retention rate were similar between groups. C-reactive protein (CRP) level (Hazard ratio (HR) = 0.98, 95% confidence interval (CI) = 0.95-0.99, p = 0.032) and primary failure (HR = 1.52, 95% CI = 1.03-2.27, p = 0.037) were significantly associated with the risk of TNFi discontinuation. Smoking (HR = 1.96, 95% CI = 1.05-3.69, p = 0.036) and Achilles enthesitis (HR = 1.93, 95% CI = 1.09-3.40, p = 0.024) were significantly associated with the risk of SEC discontinuation.

Conclusion: In axSpA exposed to a TNFi, switching to a second TNFi has comparable effectiveness to switching to SEC. SEC may be a better option in patients who experienced primary failure of TNFi, whereas an alternative TNFi may be preferred in patients with higher CRP levels or Achilles enthesitis, or who are currently smoking.

Keywords: Secukinumab; ankylosing spondylitis; second‐line bDMARD; tumor necrosis factor inhibitor.

Publication types

  • Observational Study

MeSH terms

  • Adult
  • Antibodies, Monoclonal, Humanized* / administration & dosage
  • Antibodies, Monoclonal, Humanized* / adverse effects
  • Antibodies, Monoclonal, Humanized* / therapeutic use
  • Antirheumatic Agents* / adverse effects
  • Antirheumatic Agents* / therapeutic use
  • Axial Spondyloarthritis* / diagnosis
  • Axial Spondyloarthritis* / drug therapy
  • Axial Spondyloarthritis* / immunology
  • Drug Substitution*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Time Factors
  • Treatment Failure
  • Treatment Outcome
  • Tumor Necrosis Factor Inhibitors* / adverse effects
  • Tumor Necrosis Factor Inhibitors* / therapeutic use

Substances

  • secukinumab
  • Antibodies, Monoclonal, Humanized
  • Tumor Necrosis Factor Inhibitors
  • Antirheumatic Agents