Biologic Agents Should Not Be Prescribed for Prevention of Psoriatic Arthritis

Although the development of PsA among patients with psoriasis may be delayed or prevented with bDMARDs, conflicting data suggest bDMARDs should not be prescribed solely for PsA prevention.

While it may be possible to delay or prevent the development of psoriatic arthritis (PsA) with biologic disease-modifying antirheumatic drugs (bDMARDs), these agents should not be prescribed to patients with psoriasis for the sole purpose of preventing PsA, according to study results published in the American Journal of Clinical Dermatology.

Researchers sought to assess whether PsA can be delayed or prevented with biologic treatment in patients with psoriasis in a systematic literature review. Relevant studies were sourced from the Cochrane Library, Web of Science, Embase, and PubMed databases from 2005 to March 2022 and were published in English. Studies were collected to evaluate the effectiveness of multiple skin psoriasis treatment approaches for the delay or prevention of subsequent PsA. The researchers compared the use of bDMARDs administered to treat skin psoriasis vs administration of conventional disease-modifying antirheumatic drugs (cDMARDs), phototherapy, topical treatment, or no treatment, while following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Patients in the included studies were aged 16 years and older, diagnosed with PsA, and had mild, moderate, or severe psoriasis. Biologic antirheumatic drugs included adalimumab, brodalumab, certolizumab, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, tildrakizumab, and ustekinumab. Studies with patients who were diagnosed with PsA prior to initiation of biologic treatment or who received a diagnosis of PsA before a diagnosis of psoriasis were excluded. Four articles were selected for analysis, all of which were retrospective cohort studies published in 2022 with grade B evidence (systematic review of lower-quality studies with inconsistent findings and limitations). The observation period ranged from 2.5 to 18 years across all studies.

Among the studies evaluated, 1 was conducted in North America, 1 in South America, and 2 originated in Europe. Three of the studies evaluated preselected patients (attending a single dermatology center or a dermatology-rheumatology collaboration center) whose skin psoriasis was treated with biologic agents. The fourth article was a significantly larger population-based study, with data captured from electronic health records.

At present, biologic agents should not be prescribed to unselected patients with psoriasis for the sole purpose of preventing psoriatic arthritis.

Across these 4 studies, the number and percentage of patients treated with bDMARDs varied, from n=687 (23%), n=243 (50%), and n=103 (5.9%) to n=12,893 (6.7%), respectively. In the overall population, the incidence of patients who received treatment for psoriasis and subsequently developed PsA (reported per 100 patient-years) was 1.55, 1.37, and 1.51 in the 3 smaller studies; and 0.975 in the large population-based study.

In the 3 studies conducted in dermatology/dermatology-rheumatology centers, there was a consistently lower incidence of PsA among patients receiving bDMARDs (0.55) vs topical drugs (1.65) or cDMARDs (0.81), bDMARDs (1.20) vs phototherapy (2.17), and bDMARDs (0.87) vs cDMARDs (1.64), respectively. However, in the large population-based study, the incidence of PsA per 100 patient-years for patients receiving bDMARDs was 7.72, compared with 6.1 for cDMARDs, 2.6 for phototherapy, and 0.58 for no treatment.

For the 3 studies conducted in dermatology/dermatology-rheumatology centers, the results suggested that treatment with bDMARDs conferred significantly lower risk for subsequent PsA. Results of the population-based study did not support use of biologic agents to prevent PsA in patients with skin psoriasis.

Limitations of this review include the retrospective cohort design of the included studies, the fact that 3 studies included selected patients from a single center, and collider stratification bias for those who received care from both rheumatologists and dermatologists. Further, some electronic health record data (used in the large population-based study) may have been incomplete or inaccurate.

The researchers concluded, “Currently, biologic agents should not be prescribed solely to prevent PsA in patients with psoriasis. Further research is needed to confirm these findings and to gain a better understanding of the relationship between biologic treatments for psoriasis and the prevention of PsA.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

This article originally appeared on Dermatology Advisor


Aronovich A, Novikov I, Pavlovsky L. Do biologic treatments for psoriasis lower the risk of psoriatic arthritis? A systematic review. Am J Clin Dermatol. Published online June 21, 2023. doi:10.1007/s40257-023-00801-8