Background Treatment of psoriatic arthritis (PsA) has been revolutionized by the use of tumour necrosis factor inhibitors (TNF). The National Institute for Health and Clinical Excellence (NICE) is the health authority that provides clinical guidance for England and Wales. In the treatment of moderate-severe PsA, infliximab, adalimumab and etanercept were approved by 2007, followed by golimumab in 2011. NICE permits the use of sequential biologics in rheumatoid arthritis, however switching between anti-TNFs in PsA is not endorsed at present in the UK. Thus, PsA patients who fail on 1st line anti-TNF therapy due to inefficacy/adverse effects are left with no further therapeutic options. Limited data from open label studies and registries have confirmed the potential benefits of switching between anti-TNFs.
Objectives Our aim was to assess compliance with current national guidance on a regional level in the UK, the outcome of patients who fail their 1st anti-TNF drug and obtain data in a clinical setting on the effectiveness of switching biologics in PsA.
Methods A retrospective audit was conducted up to June 2012, to include all PsA patients on a current anti-TNFs in the North-West region of England. Each rheumatology department in the region was invited to participate. Data was collected locally by a designated site coordinator, then analysed centrally using Microsoft Excel 2011.
Results Data on 548 patients was collected across 18 sites (mean age 48 years [range 20-80 years], 51% female). The mean time from diagnosis to commencing anti-TNF was 7.5 years, 28% were on biologic monotherapy and 72% were on a concomitant DMARD (84% of which methotrexate). The majority of patients were started on adalimumab 1st line (64%), followed by etanercept (34%), infliximab (2%) and golimumab (1%). At 12 weeks, 74% of patients had an adequate response. However, 24% of patients were not on their initial anti-TNF at the time of the audit (reasons included: 41% secondary inefficacy, 19% primary inefficacy, 26% intolerance, 4% pregnancy). 17% of all patients switched between anti-TNFs against national NICE guidance, with 3% switching between 3-4 biologics. Subsequent lines of biologics included anti-TNFs (including certolizumab pegol, n=1) but also rituximab (n=2), ustekinumab (n=1) and tocilizumab (n=1). 74% switched due to inefficacy, the remainder due to intolerance. In only 24% of switchers, local health authority permission was attained for funding; 4 patients had an individual funding request rejected. Of the switchers, 52% responded to 2nd line biologic therapy and 8% to 3rd line therapy; 19% were non-responders, 2% intolerant and 19% awaiting follow up to assess response to switching at the time of the audit.
Conclusions Every centre in the region participated, most sites collecting information on all eligible patients representing an accurate reflection of current practice. There is regional variation regarding policy on switching anti-TNFs in PsA. The results signify a need for updating current national guidance and support the effectiveness of switching in PsA to allow more therapeutic alternatives for the most severely affected patients.
Acknowledgements We would very much like to thank all the site co-ordinators in the North West region of England for collecting data: Dr B. Harrison, Dr S. Naz, Dr A. Madan, Dr D. Roy, Dr S. Wig, Sister J. Hawthorne, Dr P. Ho, Dr R. Muhamad, Sister J. Firth, Dr C. Sharp, Dr J. Little, Dr F. Wood, Dr M. Castelino, Dr E. Bruce, Dr L. Das, Dr F. Joseph, Dr L. Teh, Dr N. Thomas and Dr S Skeoch for co-ordinating the pilot regional audit in 2011.
Disclosure of Interest None Declared