Psoriatic arthritis: Recommendations for the use of infliximab

  • Indications: Moderate/severe psoriatic arthritis, severe psoriasis, adult rheumatoid arthritis, ankylosing spondylitis, and Crohn’s disease (pediatric and adult).
  • Dosage: 5mg/kg given intravenously at weeks 0, 2, 6 and then every 6 - 8 weeks.  Dose and interval of infusions may be adjusted as needed.
  • Response: ACR 20 at week 14 is 58%
  • Toxicities: Infusion reactions and serum sickness can occur–more commonly in patients who have developed antibodies; The incidence of infusion reactions may be reduced by concurrent administration of methotrexate; Rare cases of serious infections (ie, tuberculosis) and malignancies including hepatosplenic T-cell lymphoma (in children); there are rare reports of drug-induced, reversible side effects including lupus without renal or CNS complications, cytopenia, MS, and exacerbation of and new onset of CHF.
  • Baseline monitoring: PPD is required; LFT, CBC, and hepatitis profile.
  • Ongoing monitoring: Periodic history and physical examination are recommended while on treatment; Consider a yearly PPD, and periodic CBC and LFT
  • Pregnancy category B
  • Contraindications: infliximab at doses > 5 mg/kg should not be given to patients with New York Heart Association functional class III or IV CHF

Level of Evidence: 1 Strength of Recommendation: A

Read more about these recommendations on efficacy

In a phase III study of 200 PsA patients infliximab showed significant benefit for the treatment of psoriatic arthritis.25 Infliximab was dosed at 5mg/kg and administered intravenously at weeks 0,2 and 6, followed by every 8 week infusions. Baseline demographic and disease activity characteristics were similar to those of the etanercept psoriatic arthritis phase III trial.  At week 14, 58% of infliximab patients and 11% of placebo patients achieved an ACR20 response (p<.001).  Response to infliximab was independent of concurrent methotrexate use (46% of patients in the study were using concurrent methotrexate at a mean dosage of 16 mg per week) although the numbers of patients in each cohort were too small to have adequate statistical power, similar to observations made in the adalimumab and etanercept psoriatic arthritis trials.  At 6 months, a higher number of infliximab-treated patients achieved ACR20/50/70 responses when compared to those receiving placebo treatment (54%, 41%, 27% versus 16%, 4%, 2%, respectively).  The presence of dactylitis decreased in the infliximab group (41% to 18%), compared with the placebo group (40% to 30%) (p=.025).  Likewise, the presence of enthesitis, assessed by palpation of the Achilles tendon and plantar fascia insertions, decreased in the infliximab group (42% to 22%) compared with the placebo group (35% to 34%) (p=.016).  Utilizing the van der Heijde-Sharp scoring method (for the hands and feet), modified for PsA, infliximab-treated patients showed inhibition of radiographic disease progression at 24 weeks; HAQ scores improved for 59% of infliximab patients, compared with 19% of placebo patients, while both the physical and mental components of SF-36 scores improved for patients receiving infliximab.  The improvement in psoriatic arthritis by infliximab was sustained at 1 year.33  

References

25. Antoni C, Krueger GG, de Vlam K, Birbara C, Beutler A, Guzzo C et al. Infliximab improves signs and symptoms of psoriatic arthritis: results of the IMPACT 2 trial. Ann Rheum Dis 2005;64:1150-7.

33. Kavanaugh A, Antoni CE, Gladman D, Wassenberg S, Zhou B, Beutler A et al. The Infliximab Multinational Psoriatic Arthritis Controlled Trial (IMPACT): results of radiographic analyses after 1 year. Ann Rheum Dis 2006;65:1038-43.

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Citation note

When referencing this guideline in a publication, please use the following citation: Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008 May;58(5):851-64.



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