When PsA patients don’t respond: A practical guide to switching bDMARDs
Industry Buzz
Biologic DMARDs, such as TNF inhibitors, IL inhibitors, and abatacept, significantly reduce both clinical progression and radiographic progression.
— Colin Edgerton, MD
It may be time to switch your patient if symptoms are not improving, if there are side effects, or if inflammation is still showing up on exams, labs, or imaging after about 3 to 6 months.
—Erin Hammett, MD
Gone are the days when patients had to rely solely on conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Today, the gold standard for treatment generally includes biologic disease-modifying antirheumatic drugs (bDMARDs).
“Biologic DMARDs, such as TNF inhibitors, IL inhibitors, and abatacept, significantly reduce both clinical progression and radiographic progression,” Colin Edgerton, MD, a board-certified rheumatologist at Low Country Rheumatology in South Carolina, says. Janus kinase inhibitors (JAKi) are also commonly used.
How do you choose?
Though these drugs have undoubtedly changed medicine—and because PsA is chronic, dynamic, and heterogeneous—there is no single, magic biologic. But finding the right bDMARD is about striking a delicate balance between efficacy, risk profile, and patient goals.
Trials on anti-tumor necrosis factor agents (anti-TNFα) have shown clinical improvement in the majority of PsA patients—but not for everyone. Around 30% of PsA patients fail to respond to the first anti-TNFα, and others experience adverse events. []
Other biologics carry their own risks. For example, anti-IL-23s carry a risk of cardiovascular events in patients with high cardiovascular risk, while anti-IL-17A/IL-17Rs carry a risk of infection, especially Candida infection. []
Overall, there’s no one-size-fits-all approach. The European Alliance of Associations for Rheumatology (EULAR) guidelines suggest that for patients with an inadequate response or intolerance to a bDMARD or a JAKi, switching to another bDMARD or JAKi should be considered, including one switch within a class. []
When to switch biologics in PsA management
Erin Hammett, MD, triple board-certified physician in rheumatology, internal medicine, and lifestyle medicine, and medical director at WellTheory, says knowing when to switch a patient to a new bDMARD requires careful thought and monitoring.
“It may be time to switch your patient if symptoms are not improving, if there are side effects, or if inflammation is still showing up on exams, labs, or imaging after about 3 to 6 months,” Dr. Hammett says. “Treatment is usually adjusted proactively, because controlling inflammation early helps prevent long-term joint damage.”
If your patient is concerned about making the jump, let them know that switching biologics is a common practice in PsA management. A 2025 retrospective cohort study published in Seminars in Arthritis and Rheumatism analyzed biologic switching in PsA patients. []
The researchers looked at 3,851 PsA patients initiating bDMARDs and analyzed switchers and non-switchers. Of those 3,851, 1,848 (48%) switched biologic therapy at least once.
Most of the patients started with anti-TNF therapy as a first-line choice, but often then switched to an anti-IL17 therapy. At times, patients were cycled back to an anti-TNF or switched to an anti-IL23 or JAKi.
The researchers found that the switches occurred more often due to the patient than to the therapy itself. Switchers were more likely to be female, smokers, obese, and from lower socioeconomic backgrounds.
Further research published in Clinical Rheumatology found that patients with more severe inflammatory disease were more likely to switch due to inefficacy. [] Patients with comorbidities were also likely to switch due to side effects.
Which patients might respond best to bDMARD treatment? Younger males with a lower baseline Disease Activity Index for Psoriatic Arthritis (DAPSA), lower baseline Health Assessment Questionnaire (HAQ) score, lower baseline tender joint count (TJC), and higher baseline C-reactive protein (CRP) levels. []
Related: 50% of PsA patients show early damage: What does that mean for treatment?