Comparative effectiveness of biologics and targeted therapies for psoriatic arthritis

Objective To quantify comparative effectiveness of interleukin (IL)-12/23 antagonist (ustekinumab), IL-17A antagonists (secukinumab and ixekizumab), PDE4 inhibitor (apremilast) and tumour necrosis factor-alpha (TNF-alpha) inhibitors (infliximab, etanercept, adalimumab, certolizumab pegol and golimumab) for psoriatic arthritis (PsA). Methods We adapted a deidentified claims-based algorithm validated for inflammatory arthritis treatments to compare treatments among a retrospective cohort of commercially insured and Medicare Advantage beneficiaries with PsA from October 2013 to April 2019 in the OptumLabs Data Warehouse. Main outcomes include (1) treatment effectiveness, based on: adherence, adding or switching biologic or PDE4, addition of new non-biologic disease-modifying antirheumatic drug, increase in biologic or PDE4 dose or frequency and glucocorticoid use and (2) percentage of each group fulfilling the effectiveness algorithm. We used Poisson regression with robust variance stratified by prior PsA biologic exposure and adjusted for potential confounders. Results Of 2730 individuals with PsA, 327 received IL-12/23, 138 IL-17A's, 624 PDE4 and 1641 TNF-alpha's. Effectiveness criteria were fulfilled among 63 (19.3%) IL-12/23 recipients, 40 (29.0%) IL-17A recipients, 160 (25.6%) PDE4 recipients and 530 (32.3%) TNF-alpha recipients. Among biologic-naive individuals, IL-12/23 was less effective than TNF-alpha's with fully adjusted relative risk (aRR) compared with TNF-alpha's of 0.63 (95% CI 0.45 to 0.89). Among biologic-experienced individuals, PDE4 recipients were less effective than TNF-alpha's (aRR 0.67, 95% CI 0.46 to 0.96). Conclusions TNF-alpha's appeared more effective than IL-12/23's for biologic-naive individuals, and PDE4's for biologic-experienced individuals. These results may help inform treatment choice for individuals with PsA.