Psoriatic arthritis (peripheral disease) (PsA) Biologic Guideline

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Eligibility

Clinical Guidelines exist for the management of peripheral psoriatic arthritis from the British Society for Rheumatology (BSR). These are currently being updated and are overdue for publication. NHS GGC clinicians follow BSR advice, but due to the addition of several new drugs since guidelines were last developed, local interpretation is required. 

NICE Biologic eligibility requires:

  • The person has peripheral arthritis with three or more tender joints and three or more swollen joints, and
  • The psoriatic arthritis has not responded to adequate trials of at least two standard disease-modifying antirheumatic drugs (csDMARDs), administered either individually or in combination.
  • Treatment as described above should normally be started with the least expensive drug (taking into account drug administration costs, required dose and product price per dose). This may need to be varied for individual patients because of differences in the method of administration and treatment schedules.

Choice of Drug

A number of mechanisms of action and drugs are available as shown in table 1

  Most cost effective drug in class Alternatvives
TNF Blockade Amgevita - Adalimumab*

Etanercept*

Infliximab IV*

Golimumab

Certolizumab

Infliximab s/c*

 

IL-17A Blockade Secukinumab Ixekizumab
IL-12/23 Blockade Ustekinumab  
PDE4 Inhibitor Apremilast  
JAK Inhibitor Tofacitinib  

Table 1 *Biosimilar agents are available for these originator products.

  • The BSR guidelines related only to TNF blockade. There has been subsequent SMC guidance for each of the mechanisms of action highlighted in table 1. Eligibility for the newer agents follows the same criteria as for TNF blockade outlined in BSR guidance.
  • Preferred choice of biologic/small molecule drugs include TNF blockade, IL-17A blockade, JAK inhibition and PDE4 inhibitors, dependent on clinical circumstances
  • Il-12/23 therapy should be reserved for second line treatment on cost and efficacy grounds with the exception of patients who are unsuitable for other 1st line agents (SMC)
  • For TNF blockers and IL-17A blockers, unless clinical circumstances require a specific treatment the most cost effective agent should be used (originator or biosimilar) Currently adalimumab is the most cost effective TNFi and should be used in preference to other biologic agents unless specific clinical considerations require a specific TNFi or medicine with a different mechanism of action.
  • Confidential drug costs are emailed to all biologic prescribers on a 6 monthly basis from GGC public health pharmacy.

Withdrawal

Treatment should be discontinued in people whose psoriatic arthritis has not shown an adequate response using the Psoriatic Arthritis Response Criteria (PsARC). An adequate response is defined as an improvement in at least two of the four PsARC criteria, (one of which has to be joint tenderness or swelling score) with no worsening in any of the four criteria.
However, it is recognised that PsARC is not widely used: comparable assessment tools are acceptable in assessing response.

Treatment Time to assess response
Etanercept, adalimumab, certolizumab, golimumab or infliximab 12 weeks
Secukinumab 16 weeks
Ixekizumab 16-20 weeks
Apremilast 24 weeks
Ustekinumab 28 weeks
Tofacitinib 12 weeks

Off-label dosing and drug monitoring

  • A decision to prescribe a biologic drug for an approved condition but using doses that are ‘off label’ e.g. tapering, is a decision for the rheumatologist and patient.
  • Increasing the interval of dosing or dose reduction at same frequency could be considered when:
    1. patients have maintained remission/LDA for a sustained period
    2. Infection concerns have developed
    3. Tolerability/patient request
  • All bDMARDS and tsDMARDS are not included in near patient testing arrangements. Responsibility for any blood monitoring remains with the prescriber.
  • Use of biologic drug level monitoring (for infliximab and adalimumab) could be considered when adjusting dose, or where secondary failure has occurred to inform choice of subsequent therapy. Advice can be found at: https://www.nhsggc.org.uk/about-us/professional-support-sites/laboratory-medicine/laboratory-disciplines/biochemistry/biological-therapy-monitoring/

Last reviewed: 30 November 2020

Next review: 30 November 2022

Author(s): Martin Perry

Version: 3

Author Email(s): [email protected]

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 654