Clinical Scenario

Peripheral monoarthritis or oligoarthritis — four or fewer actively swollen joints — without poor prognostic features: no structural damage, no elevated acute-phase reactants, no dactylitis, and no nail involvement.

Prior Biologic Therapy — Target Not Achieved

This protocol is indicated when a bDMARD has been used but the required targets were not met. bDMARDs previously trialled may include adalimumab, certolizumab, etanercept, infliximab, golimumab, ustekinumab, ixekizumab, secukinumab, bimekizumab, guselkumab, or risankizumab.

Goals that were not reached on the prior line:

Sufficient improvement at 3 months
Remission or low disease activity at 6 months

Next-Step Approach (Partial Overview)

After an inadequate response to a bDMARD, the evidence-based regimen for this population involves a targeted oral therapy — specifically a JAK inhibitor — with agent selection guided by individual patient safety considerations. The complete protocol, including agent choice, monitoring, and safety criteria, is available via the link below.

References

DOI: 10.1136/ard-2024-225531

Patients with oligoarticular disease and lack of poor prognostic factors should also receive a csDMARD, but there is less urgency for these patients given the more favourable long-term prognosis.
The latter may receive csDMARDs after a longer delay, and potentially a period of symptomatic treatment alone.
In patients with peripheral arthritis and an inadequate response to at least one bDMARD, or when a bDMARD is not appropriate, a JAKi may be considered, taking safety considerations into account.
Treatment should be aimed at reaching the target of remission or, alternatively, low disease activity, by regular disease activity assessment and appropriate adjustment of therapy.

View source ↗

Psoriatic Arthritis with ≤4 Swollen Joints: When Biologic DMARD Therapy Has Not Reached the Treatment Target