Cycling or Swapping in Spondyloarthritis? Current Knowledge

Area of Science:

• Rheumatology
• Immunology
• Pharmacology

Background:

• Psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) share therapeutic options like TNF-inhibitors, anti-IL-17, and JAK-inhibitors.
• Many patients require treatment modification due to insufficient response to initial b/tsDMARDs.
• Treatment strategies include cycling (same drug class) or swapping (different drug class).

Purpose of the Study:

• To critically review the literature comparing cycling versus swapping strategies for PsA and axSpA.
• To evaluate the effectiveness of different treatment modification approaches in managing PsA and axSpA.
• To identify factors influencing treatment outcomes in PsA and axSpA patients undergoing treatment changes.

Main Methods:

• A narrative review of literature published in PubMed from inception to June 2025.
• Keywords included "Psoriatic arthritis", "axial spondyloarthritis", "ankylosing spondylitis", "non-radiographic axial spondyloarthritis", and "cycling", "swapping", "switching".
• Inclusion criteria comprised adult populations and English-language studies.

Main Results:

• For PsA, cycling and swapping appear equally effective, though patient and drug-specific variations may exist.
• For axSpA, switching to a second TNFi is viable, but overall effectiveness may decrease with subsequent treatments.
• Switching to a different mechanism of action is a valid strategy for secondary non-responders in both conditions.

Conclusions:

• Both cycling and swapping strategies demonstrate comparable success rates in PsA and axSpA.
• Patient characteristics, such as gender, may impact the relative efficacy of cycling versus swapping.
• Further assessment of risk factors is recommended for optimizing treatment strategies in PsA and axSpA.