Treatment for Rheumatoid arthritis (RA), Psoriatic arthritis (PsA) and Ankylosing spondylitis (AS) has changed immensely over the past 25 years, emerging from an approach of providing symptomatic relief, to the implementation of therapeutic regimens that affect disease activity and finally have been shown to slow or arrest structural joint damage. However, there is a paucity of data regarding the optimal choice of the second-line biologic therapy in patients with RA, AS and PsA.

Fabrizio Cantini & colleagues conducted a study in which the most consistent literature was assessed to estimate the best strategy for the second-line biologic therapy in RA, AS and PsA patients. English literature articles from available randomized, controlled trials, national biologic registries, national healthcare databases, post-marketing surveys, and open-label observational studies were extracted.

For all three rheumatic conditions, some previously stated variables including the patients׳ choice, the indication for anti-tumor necrosis factor (TNF) monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects were valid. Among RA patients, Golimumab as second-line biologic medication represented the highest level of evidence in anti-TNF failure. Further, a switching strategy is advised for patients, who experienced an adverse event. On the other hand, severe or class-specific side effects were managed with different targeted drugs. Also, the inadequate secondary response to Etanercept (ETN) should be handled with biologic agent aside from anti-TNF. During swapping, two non-anti-TNF targeted medications, Rituximab (RTX) and Tocilizumab (TCZ) showed the strongest evidence of efficacy in the treatment of anti-TNF failures. The drug, Adalimumab during switching therapy, showed beneficial evidence among PsA and AS patients with uveitis. Further, Ustekinumab or Secukinumab were preferred among PsA and AS patients due to the severity of psoriasis, of articular involvement, and the predominance of enthesitis and/or dactylitis.

Therefore, taking into consideration the insufficiency of controlled trials, evaluated from the overall study, the optimization of second-line biologic therapy may be uncertain among patients with RA, SpA, and PsA.