After a JAK inhibitor fails, why it stopped should pick what comes next

The edition in brief

In 500 treatment courses from the Japanese ANSWER registry started after a JAK inhibitor was stopped in rheumatoid arthritis, abatacept (CTLA4-Ig) was associated with more discontinuation for ineffectiveness than cycling to another JAK inhibitor when the first had failed (HR 2.83, 95% CI 1.20 to 6.70). When the JAK inhibitor had been stopped for toxicity, TNF inhibitors and IL-6 receptor antibodies were associated with fewer subsequent toxicity-related stops than another JAK inhibitor. Disease activity trajectories over 12 months did not differ. In the phase 3b APEX trial of 1,020 biologic-naive adults with active, erosive psoriatic arthritis, guselkumab sustained ACR20 responses of 71% to 74% at 48 weeks with low radiographic progression, and progression slowed in placebo patients after they switched. A single-centre cohort of 43 patients with lupus nephritis given add-on belimumab reached a stringent deep renal response (protein-to-creatinine ratio under 200 mg/g, no active haematuria) in 53.8% by 24 months. The pearl covers hydroxychloroquine dosing and retinal screening.