Early intensive therapy shows promise in psoriatic arthritis patients with poor prognostic factors

Is there a benefit to early bDMARD?

In psoriatic arthritis (PsA) EULAR - The European Alliance of Associations for Rheumatology - recommends a treat-to-target approach, and suggests more intensive therapy for people with poor prognostic factors, depending on the disease presentation. Specifically, treatment should target of remission or, alternatively, low disease activity, by regularly assessing disease activity and adjusting therapy as required.

Two recent studies suggest there is no significant benefit of early biologics over standard step-up care with methotrexate,but these did not select for poor prognosis. The aim therefore of the SPEED trial (Severe Psoriatic arthritis - Early intervEntion to control Disease) - which was funded by the National Institute for Health Research (NIHR) - was to compare disease activity in 192 PsA patients with poor prognostic factors when treated with one of three regimens: standard step-up with conventional systemic disease-modifying anti-rheumatic drugs (csDMARD), combination csDMARD, or early induction with a tumour necrosis factor inhibitor (TNFi). The primary endpoint was the mean PsA disease activity score (PASDAS) at 24 weeks. Data were presented at the 2025 annual EULAR congress in Barcelona.

At Week 24, a difference was found in PASDAS mean scores between treatment groups, with both the combination csDMARD and early TNFi groups showing evidence of a difference when compared to standard step-up care. Of note, there was no evidence of a difference between the early TNFi and combination csDMARD groups. However, by Week 48 the benefit compared to standard step-up care was seen only for early TNFi therapy.

Presenting the work, Laura Coates said "these data show that initial intensive therapy with early biologics or combination csDMARDs are superior for rapid control of early moderate-to-severe PsA. Even with only 6 months of early biologic therapy, better outcomes are maintained at 1 year in those initially receiving a TNF inhibitor."

A case series also presented at the congress aimed to describe real-world safety and effectiveness of combined biologic and targeted synthetic DMARD therapy in PsA. Andre Lucas Ribeiro and colleagues analysed prospectively collected data from the University of Toronto psoriatic arthritis cohort, which included 22 people treated with combinations of a bDMARD and either JAKi or TYK2i, with some patients trying multiple combinations. The primary indications for combination therapy were active peripheral arthritis and skin disease, including palmoplantar psoriasis.

Results showed numerical improvement across multiple disease-activity measures. In the bDMARD plus JAKi group, the most frequent combination was an IL-17i plus JAKi, and over 10.5 patient-years of exposure only one case of mild infectious stomatitis was reported, which did not result in treatment discontinuation. Additionally, IL-23i plus JAKi were used for 3.7 patient-years without any reported safety events.

For the bDMARD plus TYK2i group, IL-17i plus TYK2i were used for 8.5 patient-years, with one person experiencing two mild upper respiratory infections (URI) on bimekizumab plus deucravacitinib, prompting a switch for risankizumab plus deucravacitinib. IL-23i plus TYK2i were used for 8.3 patient-years, with two cases of mild URI leading to a switch to bimekizumab monotherapy, and one case of folliculitis where therapy was continued. One patient received TNFi plus TYK2i for 0.9 patient-years with no adverse events reported.

Combinations of bDMARD plus apremilast were also reported, with two cases of diarrhoea observed, but no infections.

Overall, the safety profile of bDMARD combinations with JAKi, TYK2i, and apremilast appear favourable. All reported infections were mild, managed without hospitalisation, and rarely led to treatment discontinuation. Furthermore, patients achieved short-term responses, with improvements in both musculoskeletal and skin domains. However, as this is an observational study with short-term follow-up, there is a need for randomised clinical trials to further explore and validate these findings.