Biologic Sequence for the Treatment of Psoriatic Arthritis Following Nonresponse: A Narrative Review

Psoriatic arthritis (PsA) is a complex, heterogeneous disease affecting multiple domains which necessitates a nuanced approach to treatment. While tumor necrosis factor (TNF) inhibitors have historically been the preferred first line therapy, increasing evidence highlights the efficacy of interleukin (IL) 17 and IL-23 inhibitors, particularly in cases of nonresponse to TNF inhibitors. These targeted biologics offer additional therapeutic options, especially for those with concomitant psoriasis (PsO) and axial disease. The proposed biologic sequence derived from clinical trial data and expert opinion incorporates PsA disease severity as well as concomitant PsO and axial disease in the setting of biologic nonresponse. This approach aims to guide clinicians in selecting the most effective therapy while conserving future treatment options. However, gaps remain in understanding the sequential use of IL-17 and IL-23 inhibitors, particularly in axial disease, emphasizing the need for further research and real-world clinical data.