Biologics and Advanced Therapies in the Management of Psoriatic Arthritis - Episode 13

Biologics in PsA: Monotherapy vs Combination Therapy

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Anthony M. Turkiewicz, MD: On the dermatology side, can you give a high level overview for all the agents, Steve, with regard to how they can be used as monotherapy? Can you combine biologics with different MOAs [mechanisms of action]? Is that done in dermatology? Give us some insight into that.

Steven R. Feldman, MD, PhD: For monotherapy, that’s the easy one because the answer is absolutely. We can use them as monotherapy. All the clinical trials in psoriasis, the drugs are tested as monotherapy. I look at psoriatic arthritis [PsA] studies, the biologics, half the patients are on methotrexate, and 10% to 20% might be on systemic steroids. In the psoriasis trial all those patients are excluded. We’re only looking at monotherapy data, so we know the drug is safe and effective as monotherapy. If I did want to use a biologic in combination, I’m relying on the rheumatology safety experience and your trials, not on anything from actual psoriasis studies.

Combining biologics is another question entirely. I don’t know that you need to do it very often because with IL-17 [interleukin-17] and IL-23 blockade and some of the better TNF[tumor necrosis factor] inhibitors, I have 9 out of 10 patients who are getting fabulous responses with monotherapy. It would be an unusual patient who needed to get 2 biologics at once. But I have them, and they’re suffering horribly, and when I need to, yes, I’ll give 2 biologics at one time if I can get it approved or covered in some way. So far it seems safe, but the numbers of patients are so small that I wouldn’t put a whole lot of confidence in my understanding of their safety.

Anthony M. Turkiewicz, MD: If you were to ask the rheumatology community, I don’t want to speak for our other 2 panelists, but the answer to that question, specifically the word biologics, the answer is no. In rheumatology we learned a lesson with our trials, this was years ago combining 2 different mechanisms. Again, we can’t compare that experience to PsA, but increased risk of infection, much less the ability to get it covered, led us to not combining biologics. The question could be asked, could phosphodiesterase, which is not a biologic, it’s a small molecule, be combined with an IL-17? I’m often asked that, and I’m really amazed at kind of the diverse answers I get.

I put it back into the audience and ask them, are you doing it? I personally do not, not just because of the prohibitive cost, but I would want to see data on that. What’s the safety with phosphodiesterase? But with regard to the effectiveness of doing so and seeing a trial with those two, I’m not a big fan of combining. Plus we have so many available MOAs now that hopefully we can find 1 and only 1 that will be healthy for our patients. Again, I don’t want to speak for all rheumatologists, but with regard to the word biologics, very rarely do I think we’d see that in a rheumatology community.

Transcript Edited for Clarity