Expert Q&A

The Management of Patients with PsA Who Did Not Respond to TNFi

Due to the availability of biosimilars, tumor necrosis factor inhibitors (TNFi) are the most used first-line biologics for the management of patients with psoriatic arthritis. With the growing number of years that TNFi have been in use, it is now common in clinical practice to have patients who do not respond to TNFi. Lead author of the recently published article, “Expert Perspective: Management of the Psoriatic Arthritis Patient After Failure of One Anti-TNF Inhibitor,”1 Ying-Ying Leung, MB, ChB, MD, answers questions about special considerations for increasing dosage and switching within medication class or across classes of medications. Dr Leung is a senior consultant in the Department of Rheumatology and Immunology at Singapore General Hospital and an associate professor at Duke-NUS Medical School, Singapore. 

Consultant360: Please provide a short overview of the case presentation and clinical challenge described in “Expert Perspective: Management of the Psoriatic Arthritis Patient After Failure of One Anti-TNF Inhibitor.”

Dr Ying-Ying Leung: The case featured a patient with psoriatic arthritis (PsA) who did not respond to a first TNFi. With the wider use of biosimilar TNFi for the management of patients with PsA for some years, not responding to TNFi, the most used first-line biologics for PsA, is a common scenario in clinical practice. We used this case to show physicians about the necessary assessment of PsA domains, comorbidities, and we highlighted special considerations for increasing dosage, and switching within medication class or across classes of medications.  

Consultant360: What are the challenges and controversies in the diagnosis and management of patients with PsA who do not have an adequate response to TNFi?

Dr Leung: There are considerations in the diversity of response of different manifestations of PsA to therapies, which require proper and comprehensive assessment. There are other factors either in the patient characteristics, comorbidities, and issues with compliance to consider in daily clinical practice to facilitate the shared decision-making process in deciding the individualized care plan for a particular patient. These factors include whether the patient is a primary or secondary non-responder to TNFi, the patient’s age, sex, and body weight. Other factors such as anxiety, depression, pain sensitization, or sleep issues may also affect their response to medications. 

Consultant360: What are some strategies for the treatment of patients with PsA who did not respond to TNFi? 

Dr Leung: There are guidelines and recommendations from different societies developed based on randomized-control trial evidence to assist physicians in considering treatment for their patients with PsA, yet there are challenges in diagnosis and treatment considerations that physicians may face in their daily practice beyond the evidence. Therefore, we presented a case scenario to illustrate the considerations behind the choices made in the expert perspectives. 

PsA is a complex condition with multiple manifestations. The decision for a change of treatment needs to be individualized, taking into consideration articular and extra-articular manifestations of the disease, comprehensive assessment of disease burden, patient profile, and comorbidities. There are several available therapeutics proven to be effective in these situations.  

Consultant360: What is the role of non-pharmacological interventions in the patient described in the case presentation?

Dr Leung: There are numerous non-pharmacological interventions that would be helpful for patients with different comorbidities. This includes dietary advice and exercise programs for weight reduction and improving general health and psychological therapies to tackle anxiety and depression, or even to help patients cope with their daily activity needs. Centralized pain and sleep disorders need to be identified and managed. Patients with sleep apnea would need to collaborate with other specialists for the appropriate management.

Consultant360: Can you summarize the gaps in the research of patients with PsA who do not have an adequate response to TNFi?

Dr Leung: There is existing evidence that guide us on the effectiveness of different therapies when patients had prior experience to biologics or TNFi, yet there remain inadequate head-to-head studies to show comparative effectiveness for different therapies in these situations. The biggest gap is the lack of biomarkers that can assist physicians in predicting patients’ responses to their next medication option.

Consultant360: What is next for research on patients with PsA who do not have an adequate response to TNFi?

Dr Leung: It would greatly improve the care of patients with PsA if researchers would identify biomarkers that predict medication response.


1. Leung YY, Kavanaugh A, Ritchlin CT. Expert perspective: management of the psoriatic arthritis patient after failure of one anti-TNF inhibitor. Arthritis Rheumatol. 2023. doi:10.1002/art.42498