Cycling versus swapping strategies for treatment of psoriatic arthritis after primary tumor necrosis factor inhibitors failure: a systematic review and meta-analysis.

Abstract

Biologic disease-modifying antirheumatic drugs (bDMARDs) are widely used to treat moderate to severe psoriatic arthritis (PsA). Tumor necrosis factor inhibitors-TNFi are the most common initial biologic owing to their long market availability, clinician familiarity, and lower cost. However, the optimal strategy following TNFi failure, cycling to another TNFi or swapping to a bDMARD with a different mechanism, remains uncertain. This meta-analysis compared both strategies in these patients. PubMed, Embase, and Cochrane Central were searched for RCTs and observational studies comparing cycling with swapping in PsA. Outcomes included: (1) lack of response; (2) 12-month retention; (3) 24-month retention; and (4) adverse events. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated. Five observational studies, including 2,300 PsA patients, were analyzed; 1,517 (66.0%) received cycling, and 783 (34.0%) received swapping strategies. Disease duration before the second bDMARD ranged from 3.7-12 years. The main cause of discontinuation of the first TNFi before switching was lack of response (including primary non-response and secondary loss of response) according to individual study definitions. No significant differences were observed between groups for lack of response (RR 0.99; 95% CI 0.70-1.41; I2=92%), 12-month retention (RR 0.91; 95% CI 0.75-1.10; I2=79%), 24-month retention (RR 0.96; 95% CI 0.53-1.75; I2=94%), or adverse events (RR 0.94; 95% CI 0.38-2.34; I2=71%). Following TNFi failure, cycling and swapping strategies show comparable retention and safety, suggesting that treatment choice may be guided by clinical characteristics and patient preference rather than clear differences in overall effectiveness.