Choosing the Appropriate Target for the Treatment of Psoriatic Arthritis: TNFα, IL-17, IL-23 or JAK Inhibitors?

Abstract

Psoriatic arthritis (PsA) is a highly heterogenous disease. Apart from arthritis and psoriasis, other manifestations can also occur, including enthesitis, dactylitis, axial-, nail-, eye- and bowel- involvement. Comorbidities are also frequent in the setting of PsA, with cardiovascular disease and mental-health disorders being the most frequent. The Rheumatologist's arsenal has many different treatment options for treating PsA. Despite their effectiveness, there are some differences in terms of efficacy and safety that might affect clinician's decision for one or the other drug. Comparing biologic DMARDs and JAK-inhibitors, one could say that they have similar effectiveness in terms of musculoskeletal manifestations. However, anti-IL-17 and anti-IL-23 drugs seem to be more effective for skin manifestations. In contrast, JAK-inhibitors and etanercept might be less effective for these manifestations. Inflammatory bowel disease and uveitis are non-responsive to etanercept and anti-IL-17 drugs. As regards to comorbidities, data are scarce, but future studies will shed light on possible differential effect of bDMARDs or JAK-inhibitors. Safety is always an important drive for choosing the appropriate treatment. Infections are the most common adverse event of these drugs. Etanercept and anti-IL-17 drugs are safer for patients having latent tuberculosis, while herpes zoster is more common in individuals receiving JAK-inhibitors. Finally, venous thromboembolism risk, should be taken into account when JAK-inhibitors are used. In this review, we comparatively present, as outlined above, the various aspects that could affect the choice of the appropriate bDMARD or JAK-inhibitor for the treatment of a PsA patient.

Keywords: JAK-inhibitors; biologic DMARDs; comorbidities; psoriatic arthritis; treatment.

Figure 1.

Efficacy of the various treatment modalities in various aspects of PsA. Green: efficacy, dark green: category is superior compared to the others, white: inefficacy or contraindication, orange: trials are underway, yellow: limited efficacy or use with caution. *Marketed for uveitis: only adalimumab; **Marketed for Crohn’s disease: adalimumab, infliximab, certolizumab, ustekinumab. Marketed for ulcerative colitis: adalimumab, infliximab, golimumab, ustekinumab, tofacitinib. VTE: venous thromboembolism; PE: pulmonary emboli; JAKi: JAK inhibitors.

Figure 2

Adverse events of bDMARDs and JAKi in PsA. Green: safe (taking into account all necessary screening procedures and prophylaxis); dark green: better safety profile compared to the others; yellow: use with caution.