FDA-Approved Biologics Appropriately Initiated as Primary Therapy for Psoriatic Arthritis

Unrecognizable man with pain in his hand talks with an unrecognizable female doctor.
Investigators analyzed the prescribing practices for patients with psoriatic arthritis at an urban rheumatology office, with an emphasis on biologic prescribing.

Biologic therapy is being appropriately initiated as the primary method for psoriatic arthritis (PsA), but treatment modifications can be made for patients receiving apremilast monotherapy, according to study results published in ACR Open Rheumatology.

In this retrospective chart review, researchers reviewed electronic medical records of 97 patients (57 men) with PsA who were seen at a rheumatology clinic between June 1, 2017 and June 1, 2018. To determine the percentage of patients prescribed biologics vs oral small molecules (OSMs), researchers examined the log of prescribing practices across different ages, sexes, and disease activities. They also reviewed charts for documentation of regions of joint involvement, joint pain, swelling or active synovitis, or dactylitis. For patients who may have qualified for biologics but remained on OSMs, investigators reviewed charts for contraindications or barriers to biologic prescribing.

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Study results showed that 66% of patients (60% of women and 70% of men) were receiving biologics monotherapy or combination therapy; 84.4% of these patients were receiving tumor necrosis factor inhibitors, and 15.6% were receiving interleukin 17 inhibitors. There was no sex bias in biologic prescribing (P =.59). Compared with nonbiologics, biologics provided superior disease control (66.6% vs 84.37%; P =.0016); OSMs provided slightly better control over apremilast monotherapy (69.5% vs 61.5%; P =.016).

This study was limited by the inability to reference validated scores of disease activity, given the lack of regular implementation in documentation. Researchers extrapolated patients’ signs and symptoms under a review of systems and physical examination to gauge disease activity and only noted disease activity for the latest documented visit within the year of observation and not monitored beyond that encounter because of the infrequent follow-up visits for most patients. There were incomplete data gathering on prior medication regimens before biologic prescribing. Elderly patients were underrepresented in the sample, limiting statistical significance.

“In accordance with the [American College of Rheumatology], patients with controlled symptoms on OSMs are being appropriately maintained on them,” the researchers concluded. “Although apremilast is allocated as an add‐on therapy, 13.4% of patients were on apremilast monotherapy, given a more favorable side‐effect profile. This [quality improvement] project reveals that in most instances, biologics are being appropriately initiated as the primary mode of therapy for patients with PsA at our outpatient practice; however, treatment modifications can be made regarding patients managed with apremilast alone.”


Khanna I, Kozicky O, Fischer H. Use of FDA‐approved medications: biologics for psoriatic arthritis in patients at an urban outpatient rheumatology [published online September 12, 2019]. ACR Open Rheumatol. doi:10.1002/acr2.11077