Up-front Secukinumab in PsA? Save

We now have an absolute plethora of agents available for use in psoriatic arthritis (PsA). In contrast we have an almost complete lack of understanding of how best to optimise use of these agents – what is the right agent at the right time for the right patient. We have tended to adopt a “traditional” approach to this uncertainty, using a step up approach, maybe starting with NSAIDs, certainly methotrexate as the first DMARD, and then probably adding a TNFi if methotrexate is ineffective. I have grown increasingly uncomfortable that this is the correct clinically-driven (as opposed to cost-saving) decision for many patients.

Abstract 1457 by Koc and colleagues at ACR 2024 has given us some further information on this topic. This was a multicentre open-label randomised controlled trial, called STAMP. All participants had early PsA with a diagnosis within 3 months of randomisation. They could have relatively low disease activity, only requiring two swollen joints.

The authors compared two treat to target strategies in early PsA, both of them relatively aggressive compared to common  real world clinical practice. The eSEC arm received secukinumab 300mg every 4 weeks, methotrexate 15mg/week orally, and a single 80mg IM methylprednisolone. They could escalate to MTX 25mg/week+TNFi if response not achieved. The SoC group received methotrexate 25mg/week and a single 80mg IM methylprednisolone. They could add sulfasalazine 2000mg/day and a TNFi if needed. The primary outcome was ACR50, with key time points of 12 and 24 weeks.

120 patients were enrolled. At week 12 ACR50 was achieved in 38% of the eSEC vs 17% in SOC (RR 2.26). Secondary endpoints were correspondingly higher to a similar degree. By week 24 ACR50 was similar, 37% of eSEC vs 40% of SoC (RR 0.93). Completion rates at 24 weeks were 98.3% for eSEC and 83.3% in SoC. There were fewer treatment escalations in the eSEC arm – 32% vs 50%).

These results are interesting. An early secukinumab based strategy was clearly superior to a MTX monotherapy strategy at 12 weeks, but the MTX group caught up by 24 weeks, some of that through escalation of treatment to a TNFi. 

Is this early superiority worth it? Many would say no, 6 months is good enough. But what if you were the patient suffering more symptoms for 6 months? Our lives are not that long, and 6 months is actually a decent chunk of lifespan. I know if I was in this situation, I would want the biologic up front. I certainly think there are some patients who clinically warrant biologic agents up front, it requires further elucidation of who these patients are, although they are most certainly not likely to be those with only 2 swollen joints like some of the trial participants here. “Cost-effectiveness” is the other ugly word here and whether those who hold the purse strings decide that such strategies are worthwhile may be a whole other question.