Title: Ixekizumab for treating active psoriatic arthritis (after DMARDs) [ID1194]
Funder: Department of Health and Social Care

Abstract: To appraise the clinical and cost effectiveness of ixekizumab within its marketing authorisation for treating active psoriatic arthritis in people whose disease has not responded adequately to previous disease-modifying anti-rheumatic drug (DMARD) therapy, or for whom DMARDs are not tolerated or contraindicated.

Lay abstract: Psoriatic arthritis (also called psoriatic arthropathy) is an inflammatory arthritis closely associated with psoriasis. It is estimated that around 1 in 5 people with psoriasis develop psoriatic arthritis (1), although this figure may be higher in people who have severe psoriasis (1). In around 70% of people psoriasis precedes psoriatic arthritis1. The prevalence of psoriatic arthritis in England in 2014 was estimated to be around 81,177 adults (2),(3). Men and women are equally likely to develop psoriatic arthritis with the peak onset being between the ages of 30 and 50 years (1). Although psoriatic arthritis is a chronic condition that progresses in the joints, its course may be erratic, with flare-ups and remissions. Arthritis symptoms can range from inflammation of the synovial membrane surrounding a joint (synovitis), ligaments and tendons (enthesitis and tendonitis), and inflammation of digits (dactylitis) to severe progressive erosion of the joints. Skin symptoms include the presence of patchy, raised, red areas of skin inflammation with scaling, which can affect any part of the body but is most commonly found on the extensor surfaces of the elbows and knees, the scalp and ears, the navel, and around the genital areas or anus. The aim of treatment is to suppress joint, tendon and ligament inflammation, and to manage the skin symptoms of the disease. Current practice involves early diagnosis and early use of non-biological disease modifying anti- rheumatic drugs (DMARDs), including methotrexate, sulfasalazine and leflunomide, in order to minimise damage to joints. Non-steroidal anti- inflammatory drugs (NSAIDs), physiotherapy and intra-articular corticosteroid injections may also be used. In addition, biological tumour necrosis factor (TNF)-alpha inhibitors may be used for treating people with active psoriatic arthritis. NICE technology appraisal guidance 199 and 220 recommend etanercept, infliximab, adalimumab or golimumab when a person has peripheral arthritis with 3 or more tender joints and 3 or more swollen joints, and the psoriatic arthritis has not responded to at least 2 standard DMARDs, given on their own or together. Ustekinumab is recommended in NICE technology appraisal guidance 340 when treatment with TNF-alpha inhibitors are contraindicated but would otherwise be considered or the person has had treatment with 1 or more TNF- alpha inhibitors. Apremilast, certolizumab pegol and secukinumab are also recommended as options in NICE technology appraisal guidance 433 and 445, respectively; for people whose disease has not responded to at least 2 standard DMARDs. Certolizumab pegol is also recommended when a tumour necrosis TNF-alpha inhibitor stopped responding after the first 12 weeks and secukinumab is also recommended when TNF-alpha inhibitor has not responded within the first 12 weeks or has stopped responding after 12 weeks or contraindicated. Biosimilar products of the biological therapies are available for use in the NHS. References 1 Psoriasis Association (2014) ‘Psoriatic Arthritis’ Accessed March 2017 2 Ogdie, A., Langan, S., Love, T., Haynes, K., Shin, S., Seminara, N., Mehta, N., Troxel, A., Choi, H., Gelfand, J. (2013) ‘Prevalence and treatment patterns of psoriatic arthritis in the UK’. Rheumatology (Oxford) Mar 52(3): 568-75 3 Office for National Statistics (2015) ‘Population estimates mid-year 2014’

Research activity codes: 6.1 PHARMACEUTICALS
Health categories: INFLAMMATORY AND IMMUNE SYSTEM