Q&A: Ustekinumab Versus TNF Inhibition in Psoriatic Arthritis

In psoriatic arthritis (PsA), ustekinumab (Stelara, Janssen Immunology), an IL-12/23 inhibitor, and tumor necrosis factor inhibitors (TNFi), when used for 6 months as first-line, second-line or third-line treatment showed similar achievement of predictors of low disease activity (LDA) and remission, according to a study published in Annals of the Rheumatic Diseases.¹

Josef S Smolen, MD

In this Q&A, corresponding author Josef S Smolen, MD, a professor at thedivision of rheumatology in Medical University of Vienna in Austria, discussed the research and its findings.

This prospective, observational cohort study, dubbed PsABio, aimed to evaluate the 6-month effectiveness of ustekinumab versus TNFi in patients with PsA who received first-line to third-line ustekinumab or a TNFi. Researchers assessed the achievement of clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) LDA/remission, and minimal disease activity (MDA)/very LDA.

At 6 months, of the 426 participants receiving ustekinumab and 442 receiving TNFi, 45.7% and 50.7%, respectively, achieved cDAPSA LDA. Further, cDAPSA remission was achieved in 14.9% and 19.2%, and MDA in 26.4% and 30.8%, respectively. Propensity score-adjusted odds ratios of reaching cDAPSA LDA and MDA were 0.73 (CI: 0.46-1.15) and 0.87 (CI: 0.61-1.25) with ustekinumab and TNFi, indicating no significant difference. Safety data were similar between the groups.

Rheumatology Network: Why was the study conducted?

Josef S Smolen, MD:TNF-blockers are still regarded the gold-standard in treating PsA when conventional biologic disease-modifying antirheumatic drugs (DMARDs) have failed. Here we compared the overall effectiveness of ustekinumab with TNF-inhibition in a real-world setting.

RN: What were the surprises from the findings?

JS:While there were no true surprises, it is noteworthy that ustekinumab was more frequently used in patients who had failed biologic DMARDs, a population of patients where such agents are usually less efficacious than in earlier lines of treatment. When correcting for these and other aspects by so called “propensity score adjustment” for imbalanced baseline variables, ustekinumab showed similar overall effectiveness as TNFi.

RN: What is the current practice and how could the findings possibly change things?

JS:The current practice is to start with a TNF-blocker, but these data show that ustekinumab has similar benefit for PsA patients.

RN: What are the takeaway points for clinicians?

JS:Ustekinumab has similar benefit for PsA patients as TNF-inhibitors and this should be conveyed to the patients during the shared decision process.

RN: Is there anything else you would like to add?

JS: I would like to refer people to EULAR’s PsA management recommendations, where treatment strategies are detailed and include IL-17 inhibition and where each of these drugs is already recommended at similar levels; indeed, the PsABio results confirm the EULAR PsA management recommendations.

Reference:

Smolen JS, Siebert S, Korotaeva TV, et al

Effectiveness of IL-12/23 inhibition (ustekinumab) versus tumour necrosis factor inhibition in psoriatic arthritis: observational PsABio study resultsAnnals of the Rheumatic Diseases Published Online First: June 23, 2021. doi: 10.1136/annrheumdis-2021-220263