The development of biologics and small oral molecules has recently changed the scenario of pharmacologic treatment of systemic
rheumatic diseases and it has become a real revolution. These drugs have innovative mechanisms of action, based on the inhibition of specific molecular or cellular targets directly involved in disease pathogenesis. This new scenario has lead to a regular update of the management recommendations of several institutions, such as those for
Rheumatoid Arthritis treatment that address the use of conventional and
biologic therapies including
TNF inhibitors (
adalimumab,
certolizumab pegol,
etanercept,
golimumab,
infliximab),
abatacept,
rituximab,
IL-6 inhibitors (
tocilizumab and
sarilumab),
biosimilars and small oral molecules (the
JAK inhibitors tofacitinib and
baricitinib). Monotherapy, combination
therapy, treatment strategies (such as treat-to-target) and the targets of sustained clinical remission or low disease activity are the final goal of the guidelines for rheumatic patients management. In another condition represented by
Axial Spondyloarthritis guidelines suggest to start first with non-steroidal anti-inflammatory drugs to improve lifestyle and reduce spine
inflammation, but if this is not achieved in 2-4 weeks it is important to consider the use of local
therapies (i.e.
glucocorticoid injections) or to start
biologic therapy such as
TNF inhibitors and then eventually switching to another
TNF inhibitor or swapping to
IL-17 inhibitor. In the case of active
Psoriatic Arthritis, guidelines suggest to start with non-steroidal anti-inflammatory drugs and even local
glucocorticoid injections especially for
oligoarthritis, then to start conventional
therapies if lack of efficacy, and finally start biologics or small oral molecules in the presence of drugs toxicity, unfavorable prognostic factors and still active
arthritis. In several cases, active
Psoriatic Arthritis patients develop a complex clinical condition with comorbidities such as diabetes,
inflammatory bowel disease and high risk of
infections, and for this reason the American College of Rheumatology and the National
Psoriasis Foundation have developed specific guidelines for their management.
Biologic and new small molecules
therapies are very expensive, but the availability of
biosimilars offers the opportunity of reducing the treatment cost and significantly decreasing the cost of originators as well. In fact, we live in a period characterized by the need to rationalize costs of these drugs, to allow treating a higher number of patients and to maintain a homogeneous possibility of treatment choice. For these reasons, we need to follow scientific guidelines and patients' clinical conditions to choose the correct treatment, also based on the economic burden of
therapies.