What Happens When You Stop Taking a Biologic Treatment for Psoriatic Arthritis?

Biologics have advanced the treatment for psoriatic arthritis (PsA) and vastly improved outcomes for many people. But these medications come with side effects and can increase the risk of adverse events during surgery, pregnancy, and other life events.

Stopping a biologic can result in the return of PsA symptoms. A number of considerations can help you decide whether it’s right to pause or cease your biologic medication.

What is psoriatic arthritis?

PsA is an autoimmune condition that causes inflammation in the joints. Treatment for PsA depends on the severity of the symptoms. First-line medications for mild PsA include over-the-counter medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen.

If first-line treatment is not effective, a doctor may recommend one of a class of disease-modifying antirheumatic drugs (DMARDs).

Biologics are a particular kind of DMARD that target specific parts of the immune system to reduce inflammation. Conventional DMARDs, like methotrexate, work on the immune system more generally.

When might you take a biologic for psoriatic arthritis?

If conventional options have not helped you reach your treatment goals, you might consider a biologic. You may also look into a biologic if you have moderate to severe PsA.

There are two main types of biologics used to treat PsA, each with a unique target and with its own benefits and risks:

• Tumor necrosis factor-a (TNF) inhibitors: Adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade)
• Interleukin inhibitors: Ixekizumab (Taltz), secukinumab (Cosentyx), guselkumab (Tremfya), risankisumab-rzaa (Skyrizi), and ustekinumab (Stelara)

Other classes of biologics that may or may not have a role in the treatment of PsA are B cell inhibitors such as rituximab (Rituxan) and selective co- stimulation modulators like abatacept (Orencia).

Some doctors may recommend a treatment plan that includes a biologic along with a conventional DMARD, such as methotrexate.

When and why might you take a break from your biologics?

Biologics are generally safe and effective treatments. However, because of how they affect your immune system, they can leave the body vulnerable to infection and have other side effects. You may decide to stop your biologic treatment when the risks outweigh the benefits.

Some factors that may indicate it’s time to take a break include:

Pregnancy or breastfeeding

A 2015 review found that there’s been little research into the effects of biologics during pregnancy and breastfeeding. The American College of Rheumatology recommends stopping some kinds of biologic treatments during gestation and lactation.

Diagnosis of a new medical condition

Treatment for some conditions, such as cancer or diabetes, can increase your risk of infection. If you receive a new diagnosis, your doctor might suggest you stop using a biologic for PsA.

Plans to undergo surgery

Surgery comes with the risk of infection. If you’re about to undergo a procedure, your doctor may discuss a plan to pause your biologic prior to the event and during your recovery.

Receiving vaccinations

Some vaccines contain live virus and present a risk to people taking biologic medications. Examples include the smallpox, yellow fever, and measles, mumps, and rubella vaccines.

It’s a good idea to talk with your doctor about coordinating your vaccination schedule with your biologic treatment.

Also, since biologics increase the risk for infection, it’s recommended that you get vaccinated against common infections such as influenza, pneumococcus pneumonia, shingles, hepatitis B, and COVID-19 before starting them.

Each individual’s vaccine recommendations should be tailored to their specific needs, taking into account prior vaccine history and what they may be at risk for.

Moving to certain regions

There’s a higher risk of a serious condition called histoplasmosis in certain geographic regions such as the Ohio and Mississippi River Valley. If you’re going to relocate to any of these areas, you may want to discuss whether to continue your biologic treatment.

Low disease activity

Most doctors recommend continuing with a biologic treatment even after you have achieved minimal or low disease activity. If treatment stops, people often experience a later flare or relapse.

What happens if you stop taking a biologic?

Stopping a biologic can cause your PsA to relapse, or cause you to experience a flare if you had achieved remission.

A 2017 paper reviewed the success of dosing down, or reducing the dose, of biologics in people with rheumatic disease. It cited previous research that of those who had discontinued TNF therapy for PsA after remission, 44.9% relapsed in a median time of 29.2 months.

A 2021 double-blind study found that people with PsA who achieved remission with ixekizumab relapsed more quickly if the biologic was withdrawn instead of continued.

If you pause your biologic, you may no longer experience the drug’s side effects. But over time, stopping and starting a biologic can cause the medication to not work as well.

You may also have a lower risk of infection, so in the case of some life events, like pregnancy or surgery, it may be a reasonable option.

What are the alternatives to stopping treatment?

Your doctor can help you determine what options are available for your particular situation. If your biologic has stopped working, you may be able to switch to a different biologic instead of stopping treatment completely.

Talking with your doctor

If you’re considering stopping your biologic treatment for PsA, you may want to discuss some issues with your doctor. Some questions people might ask include:

• Can I switch my biologic treatment to a different one to increase efficacy or reduce side effects?
• Can I take my biologic if I get pregnant?
• How long before surgery should I stop my biologic?
• When can I receive vaccinations?
• Can I return to conventional treatments like NSAIDs and non-biologic DMARDs?
• Is it possible to reduce or taper down my dose if I achieve remission?

It’s usually a good idea to talk with your doctor whenever you have questions or concerns about your medications, so you can decide on the treatment plan that’s best for you.

Frequently asked questions

Here are some questions people often ask about biologic treatments for psoriatic arthritis:

Can psoriatic arthritis go into remission without medication?

Most people achieve remission through one or a combination of medications. Even those with mild PsA usually use over-the-counter drugs such as NSAIDs to control inflammation.

How long do you stay on biologics for psoriasis?

People generally stay on a biologic for as long as it’s effective. It’s safe to use a biologic indefinitely.

Can I go back on biologics after stopping them?

You can restart a biologic after stopping. Biologics work best if a person takes them continuously, as stopping and restarting the medication can lead to reduced effectiveness.

The takeaway

Biologics are generally safe and effective drugs for PsA. Stopping a biologic can reduce the medication’s effectiveness and cause the return of PsA flares.

You and your doctor may nonetheless decide to stop a biologic when the risks outweigh the benefits.