Professor Peter Nash on switching vs cycling drug classes in PsA non-responders; predicting PsO to PsA progression; and combination biologics and targeted therapies in SpA.
We asked four leading Australian rheumatologists to talk us through research presented at ACR 2022 that excites them and promises interesting changes for the future.
In this article, Professor Peter Nash of Griffith University discusses some of the highlights in psoriatic arthritis and spondyloarthritis, including switching vs cycling drug classes in PsA non-responders, predicting PsO to PsA progression and combination biologics and targeted therapies in SpA.
For research that would change practice now, Professor Nash pointed to a study from Portugal (#2149) that looked at whether you should cycle within a drug class or switch if you have a PsA patient who’s not doing well.
The 450 patients cycled from one TNFi to another, or switched from TNFi to another mode of action, in particular an IL-17 inhibitor (secukinumab or ustekinumab).
“There was efficacy either way, and they had real trouble showing whether you should cycle or switch,” said Professor Nash.
However, he said, other papers in the session suggested that “changing mode of action is more likely to be successful than switching interminably within a class”.
Another interesting study considered the question of whether to taper or stop medication in patients with inactive non-radiographic axSpA.
In the GO-BACK study, poster #0545, patients were eligible for a withdrawal protocol if they had achieved inactive disease after 10 months of golimumab treatment. Of those who stopped medication, only 33% remained without disease flare. However, among those who tapered from monthly to two-monthly doses, 68% didn’t flare.
“So the bottom line is, if TNF patients are doing well, whether it’s non-radiographic or radiographic axSpA, increase the duration between injections,” said Professor Nash.
“But please don’t stop, or 60-70% of people will pay in the subsequent six months. The only good news is that you can recapture them quite quickly if you restart therapy.”
Over the next decade, said Professor Nash, there’s going to be a series of tools like the Prediction of Psoriatic Arthritis Tool (PRESTO) trying to help us decide which PsO patient is going to develop PsA.
In a 14-year study of 635 people with PsO, researchers looked at the characteristics of those who developed PsA. There were 51 patients who developed it within a year, and 71 within five years.
“It’s not rocket science,” said Professor Nash. “It’s age, it’s males, family history, nail pitting, stiffnesses, having symptoms already, having to use a biologic for psoriasis, and so on.”
Another predictive test was a proof-of-principle study with 10 psoriasis patients using PET-CT imaging to visualise fibroblast activity at synovial and entheseal sites (#1235). Patients were followed up to determine who developed psoriatic arthritis.
“They looked at a specific kind of PET that doesn’t just look at the synovium or enthesis, but looks at the fibroblasts and the stromal cells at the synovio-entheseal region,” said Professor Nash.
Of the seven patients who had uptake at synovio-entheseal sites, 86% (six of seven) progressed to PsA. The three patients who were negative did not develop PsA within the 16-month follow up.
“So I’m not saying do this,” he said.
“I’m saying that over the next decade, you’ll see many things – tools and imaging and microbiome and biomarkers – trying to pick the PsO patients who progress and whether you intervene with advanced therapies to prevent that progression.”
As for future developments, Professor Nash is excited by the possibilities of combination biological or targeted therapies, presented in poster #1044.
“I think we’re going to start combining therapies at day one, to get people into a better remission than we can do at the moment, then a reduced maintenance therapy over time,” he said.
The retrospective multicentre Spanish study included 29 patients with SpA (of whom 20 also had inflammatory bowel disease) who’d had simultaneous combined use of two biological or targeted synthetics with different therapeutic targets for a minimum of three months.
The study authors considered the efficacy/safety ration “acceptable”, with two serious AE identified (non-infectious diffuse pulmonary infiltrates and a staphylococcal bacteriemia).
In summing up his review, Professor Nash said, “So to change practice now, I’ll probably switch rather than cycle and taper rather than stop. Changing practice over the next decade will be about trying to pick the PsO patients that will develop PsA. And then for the future, I think we’re going to see combination studies to get better outcomes for the patients, provided there’s no safety penalty.”
Professor Peter Nash is an educator and researcher at Griffith University in Queensland and director of the Rheumatology Research Unit on the Sunshine Coast. He is also on the international steering committee for the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
Rheumatology Republic invited Professor Ranjeny Thomas, Associate Professor Alberta Hoi, Associate Professor Peter Wong and Professor Peter Nash to discuss three of their favourite ACR 2022 abstracts or sessions in a webinar held at the conclusion of the conference.
Read Professor Thomas’s take on RA research here, Associate Professor Hoi’s lupus picks here and Associate Professor Wong’s covid and infection highlights here.
You can see a recording of the full webinar here, with in-depth discussion and informative slides.
