Cycling Versus Swapping After First-Line TNF Inhibitor Failure in Psoriatic Arthritis: Real-World Insights From the Argentine RECCAPSO Registry

Objectives: Cycling within the same mechanism of action (MoA) or swapping to a different MoA are 2 strategies after failure of advanced therapy in psoriatic arthritis (PsA). We described the frequency, clinical characteristics, and treatment trajectory of cycling versus swapping at the first switch in a multicenter Argentine PsA cohort. Methods: Retrospective cohort analysis of 350 consecutive adults with PsA fulfilling CASPAR criteria and enrolled in the RECCAPSO registry. Among 179 patients with documented first-line treatment lineage, the comparative analysis was restricted to those who discontinued first-line TNFi because of primary inefficacy or secondary loss of response. Cycling was defined as switching to another TNFi and swapping as switching to a different MoA. Between-group comparisons were exploratory and performed using Mann-Whitney U and Fisher exact tests. Results: Of 350 patients, 183 (52%) received advanced therapy; 60/179 (33.5%) experienced first-line failure, all while receiving TNFi. Of these, 18 (30%) cycled and 42 (70%) swapped. The median interval from first-line to second-line initiation was 18 months [interquartile range (IQR): 4 to 60] in cyclers and 19 months (IQR: 6 to 56) in swappers. At the first switch, swappers had higher C-reactive protein (3.4 vs. 1.6 mg/L; P =0.04) and numerically less enthesitis (38.1% vs. 66.7%; P =0.08). At the subsequent cross-sectional assessment during second-line therapy, DAPSA remission was observed in 18.4% of swappers and 0% of cyclers ( P =0.09). Third-line therapy was initiated in 77.8% of cyclers and 31.0% of swappers ( P =0.0015); among those reaching a third line, the median interval from second-line to third-line initiation was 5 months (IQR: 2 to 9) and 13 months (IQR: 4 to 34), respectively. Conclusions: Swapping was the predominant strategy after first-line TNFi failure. Cyclers more frequently initiated a third line and, among those who escalated, did so earlier.