Ustekinumab: highly efficacious in PSA independent of methotrexate

Monotherapy with the IL-12/23 blocker ustekinumab demonstrated equal efficacy in patients with active psoriatic arthritis (PsA) compared with the combination of methotrexate and ustekinumab. In contrast, the addition of methotrexate was responsible for more side effects and did not enhance efficacy or quality of life in these patients.

Although biologics like tumour necrosis factor (TNF) inhibitors or cytokine blockers are the most effective agents in treating active PsA, randomised clinical trials usually require treatment failure or intolerance of conventional disease-modifying antirheumatic drug (DMARDs)/methotrexate before initiation of a biological treatment. In most countries, biologics can only be prescribed in patients not responding to previous conventional therapy with DMARDs. Methotrexate is often used as a first-line agent in these patients. “The value of methotrexate together with biologic DMARDs is still unclear in PsA,” said Dr Michaela Köhm (Goethe-University Frankfurt, Germany). Therefore, Dr Köhm and her team designed an investigator-initiated, randomised, placebo-controlled trial in active PsA to examine whether treatment outcomes with ustekinumab in combination with methotrexate (either newly initiated or ongoing) differ from ustekinumab monotherapy [1].

In total, 173 patients with active PsA were randomised to ustekinumab with methotrexate or ustekinumab with placebo. Baseline data were well balanced between treatment groups. Baseline differences were only seen in dactylitis (24.1% vs 19.0%), body surface area (BSA; 2.9% vs 1.0%), and quality of life, assessed in the Dermatology Life Quality Index (8.6 vs 6.9).

At week 24, the mean DAS28-ESR disease activity score decreased by 1.7 points for both the combination and for ustekinumab plus placebo groups. Changes in other outcomes at week 24 were also similar between groups. The effect of blinded initiation or withdrawal of methotrexate on ustekinumab efficacy was also explored in subgroups of patients who were treatment-naïve or pre-treated with methotrexate, respectively. Again, adding methotrexate had no significant impact in 24 weeks. Patients that received methotrexate together with ustekinumab experienced 18% more adverse events and the only 2 serious infections documented in this study.

The authors concluded that ustekinumab is an effective treatment for active PsA, independent of methotrexate use. As the latter has no positive impact on efficacy for arthritis, enthesitis, dactylitis, skin, quality of life, and function, there is no evidence to either add methotrexate or maintain ongoing methotrexate when starting ustekinumab.

1. Köhm M, et al. Neither add-on nor withdrawal of methotrexate impacts efficacy of IL12/23 inhibition in active PsA: data from a multicenter investigator-initiated randomized placebo-controlled clinical trial on arthritis, dactylitis, enthesitis, psoriasis, QoL and function. Abstract L12, ACR Convergence 2021, 3–10 November.

 

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Posted on 14 January 202229 February 2024