Biologics comparative research

Hello Everyone,
Quick history, my wife has PsA. She was taking Humira in 2017 which was working great. Late 2018 early 2019, she had few swollen lymph nodes after biopsy which came as lymph node tuberculosis. It was a long 18 months treatment which was completed in mid 2020. Because of all this Humira was stopped and rheumy recommended we start with methotrexate. But Mtx has its limitations and now we are noticing it.

But we are also reluctant to go back to Humira because we don’t want TB to relapse or reactivate. I wanted to know if their are any papers or research which compares if some biologics are better than others in this situation.

Any input will be great

I very much doubt sadly if there are any cogent enough research papers on this, given the lack of comparison data on biologics just anyway. However there are tons more biologics than just humira to treat PsA. You could lose the group humira is in being ‘anti-TFNa’ ones and start looking into interleukins ones like Cosentyx or Talz or the JAK inhibitors. The likes of humira and enbrel did nothing for my PsA but Cosentyx is working a lot better. So what is your rheumy team thinking of what is next?

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Is she able to do a course of treatment to eliminate the TB? Wasn’t she tested for it before she started Humira? This article was interesting - Guidance for the management of patients with latent tuberculosis infection requiring biologic therapy in rheumatology and dermatology clinical practice - PubMed

I wish her luck with this.

Hi Stoney,
She has already completed her treatment for TB and even before starting she was also tested for it. She had latent tb so we did 9 months of treatment with inh before starting Humira. But unfortunately that preventive treatment didn’t work and she still got lymph node TB.

But now her treatment is done and doctors are suggesting that we can start biologics again. But this time we want to be sure we make correct choice.

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I like the approach using different biologics with non tang inhibitor. I was just hoping May be there some research in which situations one is better than other.

Our rhemy is suggesting cosentyx too but again she was not able to find any comparative study. I am also asking one of my friend who works for Novartis and check if they have done studies comparing Humira vs Cosentyx.

Sadly the present focussed research is utterly dire and completely disinterested in comparing biologics. Like you, I wonder why on earth that is.

To sufferers needing biologics it all reeks of incoherency. And yes it does for the sole reason that research scientists always need funding and no big research institute is that interested in patients, they are more interested in making profit.

As for the intelligent, curious, genius researchers of which there are loads, they frankly don’t get paid an awful lot to be able to follow their passion and the interest their seriously magnificent brains are posing. They like us also need to earn enough to put food on the table.

So it’s totally unlikely you’ll find such research. Simply so sadly because there isn’t any.

It’s bizarre there’s none, isn’t it? Blame the funding of research before you blame the scientists though. Venture capitalists the world over fund such research without caring a damn about the result or the patients unless they can make a profit.

Imagine being someone with the wherewithal intelligence wise to research all this but unable to convince the venture capital funders that it will make a profit return. That happens to truly genius scientists every goddamn day sadly.

Comparing biologics in varying scenarios does not make a profit hence there are no such studies of any importance to the type of issues you and your wife need answering.

It’s sadly what we deal with daily in our medical decisions as a patient. No research just try and see and hope for the best. Sigh.

Sadly PsA is never Covid either. There with Covid, the scientific community globally did just the most stunning amazing scientific work. But they’ll never do that for PsA and TB issues or much else frankly.

Hugs. Xxx

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I came across this paper Risk of Tuberculosis Reactivation in Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis Receiving Non-Anti-TNF-Targeted Biologics . Which at high level suggested that non anti-tnf inhibitor might reduce the risk of TB activation.

But there is lot of technical jargon which is way above my knowledge in this area. But I wanted a 2nd set of eyes to go through this paper and make sure my interpretation of this paper is correct.

Thank you,

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I am going to make an assumption that one of your wife’s parents had active TB, and that was the point of exposure. Latent TBA can lay dormant for decades, and biologics can allow it to go active. The medical history of your wife should have resulted in a secondary test for latent TB. Even then it is kind of a risk versus reward type of situation. Unfortunately, sometimes the only thing that you can do is take the best professional advice you can receive, and weigh the potential benefits against the risk.

My grandmother on my father side died due to TB, my father has latent, and for me I get extra blood work. The biggest positive factor that you have going forward is that the condition is known and can be tested for, and monitored, regardless of the drug that she is taking. Again, it is about risk vs reward, in this case the risk can be managed and monitored.

That’s really interesting, that even two generations down that you get extra monitoring. That’s really good information for anyone with a known family history of TB.

It does seem your wife was very unlucky given she was TB tested before humira, treated for her latent TB but yet still got this lymph node TB issue. And has now undergone yet more TB treatment. But surely now they have her in a safer place TB wise? What is their prognosis on that?

The paper you’ve enclosed rather interestingly says no one developed TB from taking Cosentyx which hits the interleukin or IL17 too. Overall the paper is telling me that non anti-TFNa biologics aren’t such a risk TB wise. But as I said earlier comparative studies on which biologic are best are pitifully few. It’s still a case of try and see.

Great paper, thank you. To my eyes I interpret it the same as you - the non-TNF inhibitor biologics they tested seem to have extremely low (or as they themselves stated - negligible) risk of reactivating latent TB.

The ones they reviewed for PsA were Stelara and Costenyx.

For Stelara, no active cases developed in 167 patients positive for LTBI. So it seems to me that the word negligible is fair.

For Costenyx, there were no recorded TB activations in the trials, but… they do note real-world data is lacking (were people even allowed in the trials if they had latent TB?). Not unreasonably they have concluded it’s likely safe too due to mode of action and lack of any recorded reactivations at all.

As such, sounds like your Rheumy is onto it.

Funny nobody talks much about Stelara with PsA any more - seemed to be tried a lot 7 or 8 years ago but I hardly ever hear of anyone starting on it for PsA now.

Actually, I was exposed to my grandmother at a young age, so there is no second generation.

That makes more sense now. Thanks for clarifying.

I’m kind of surprised that @tntlamb hasn’t commented on this.

The reason I didn’t comment is frankly I didn’t understand it… They State “The availability of non-anti-TNF-targeted biologics has widened the therapeutic strategies in patients with RA, PsA, and AS, allowing optimization in the biologic choice of function of several clinical variables. Among these, the TB reactivation risk should be assessed in all patients, and in case of positive results, non-anti-TNF- α -targeted biologics for RA, UTK, or SCK for PsA, and SCK for AS represent the safest option”

It may be the safest option but it flys in opposition to the more recent recoomendations based on Physician reports and Meta analysis in the newly develope protocaol by the 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis adopted in 2020.

There was some mention in another thread about what happened to Stelera (Ustekinumab) What happened to Stelera was it may be helpful for Psoriasis, helpful for IBD but for actual Arthritis, it was a dud (20% improvement in 50% of patients) This paper: goes into a lot of detail about symptoms and effected areas (axial, hands feet etc) and what worked best. Now it may be an overstatement but generally their conclusion based on 20 years of meta data is that non-anti-TNF-targeted biologics don’t work or don’t work well and that anti-TNF- α -targeted biologics should be the first choice.

Now the paper in question has a lot of information but frankly my opinion is that it is all superfluous. I’d add to that is that Docs are lazy and because TB (latent or otherwise) is so rare that more than a few Rheumies just go through the motions in a pre-biologic work up so they can check a box. The easiest is a skin test (mantoux or TST) Give a poke and three days later take a peek no reaction and no TB. FWIW my clinic and many others do BOTH tests, a TB skin test (known as a TST or Mantoux) and a blood test (known as an IGRA). It still isn’t 100% but it its better than going through the motions…

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