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. 2025 Jun 25;11(2):e005566.
doi: 10.1136/rmdopen-2025-005566.

Cycle versus swap strategy after TNFi discontinuation in psoriatic arthritis and axial spondyloarthritis: a quasi-experimental study

Ilse van Es  1 , Johanna E Vriezekolk  1 , Nathan den Broeder  1 , Lisan de Beijer  1 , Alfons A den Broeder  2   3 , Noortje van Herwaarden  2   4 , Elien Mahler  2 , Emmerik F A Leijten  5   3
Affiliations

Cycle versus swap strategy after TNFi discontinuation in psoriatic arthritis and axial spondyloarthritis: a quasi-experimental study

Ilse van Es et al. RMD Open. .

Abstract

Objectives: To compare a bDMARD mode of action cycle vs swap treatment strategy in patients with psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) after first tumour necrosis factor inhibitor (TNFi) discontinuation.

Methods: In December 2019, our local treatment protocol for PsA and axSpA changed from a cycle strategy (first TNFi to second TNFi) to a swap strategy (first TNFi to IL-17i). We performed a retrospective comparison of the 3-year drug retention rate using multivariable Cox regression (ref: cycle group) and disease activity (DAS28-CRP for PsA, BASDAI for axSpA) in patients with a clinical diagnosis of PsA and axSpA. For subgroup analyses, Cox regression models were stratified by sex, reason of first TNFi discontinuation, and (non-)radiographic status in axSpA.

Results: In PsA patients (n=406), there was no overall significant difference in drug retention between strategies (HR: 1.17 (95% CI: 0.87 to 1.58), p=0.29), but male PsA patients had a significant higher risk for treatment discontinuation following a swap strategy. In axSpA patients (n=335), the swap strategy was overall associated with a higher risk of treatment discontinuation (HR: 1.46 (95% CI: 1.03 to 2.07), p=0.04). Patients who discontinued their first TNFi due to inefficacy and patients diagnosed with radiographic axSpA were at significant higher risk for treatment discontinuation following a swap strategy. No significant differences in disease activity were found for treatment strategies in PsA or axSpA.

Conclusion: In PsA, the cycle and swap treatment strategy performed similarly, while in axSpA, the cycle strategy was associated with a significant higher drug retention rate.

Keywords: Arthritis, Psoriatic; Axial Spondyloarthritis; Interleukin-17; Treatment; Tumor Necrosis Factor Inhibitors.

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Conflict of interest statement

Competing interests: IvE: None declared, JEV: Received grants from Novartis and Eli Lilly, unrelated to the current study, NdB: None declared, LdB: None declared, AAdB: Received grants for research and quality of care projects to the institution from Lilly, Abbvie, Galapagos, Novartis, Pfizer, Gilead, Sanofi, Biogen and Celltrion, unrelated to the current study, NvH: None declared, EM: Received grants for research and quality of care projects to the institution from Abbvie, Eli Lilly, Pfizer, Novartis, unrelated to the current study, EFAL: Received funding for research grants from Novartis and Eli Lilly, unrelated to the current study.

Figures

Figure 1
Figure 1. Second bDMARD drug retention in psoriatic arthritis. The Kaplan-Meier survival plot shows the 3-year drug retention rate of a second TNFi in the cycle group and a first IL-17i in the swap group in patients with PsA. Ticks indicate censored data. No significant difference in drug retention was seen between the cycle and swap strategy. TNFi, tumour necrosis factor inhibitor.
Figure 2
Figure 2. Second bDMARD drug retention in axial spondyloarthritis. The Kaplan-Meier survival plot shows the 3-year drug retention rate of a second TNFi in the cycle group and a first IL-17i in the swap group in patients with axSpA. Ticks indicate censored data. The cycle strategy was associated with significant higher drug retention rates. TNFi, tumour necrosis factor inhibitor.
See this image and copyright information in PMC

References

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