BackgroundThere are currently ten biologic and targeted synthetic (b/ts)DMARDs acting via five different modes of action (MOA) available for the treatment of psoriatic arthritis (PsA) in Australia. b/tsDMARDs are government-subsidised, and once the patient reaches the eligibility requirements, the clinician can prescribe the agent deemed most appropriate. Available agents include TNF inhibitors (TNFi, adalimumab, etanercept, infliximab, golimumab, certolizumab pegol), IL-17A inhibitors (IL-17Ai, secukinumab, ixekizumab), and IL-12/23 inhibitor (IL-12/23i, ustekinumab). Two new MOAs were recently added to the rheumatologist’s armamentarium: the first JAK inhibitor (JAKi, tofacitinib) was subsidized from May 2019 followed by upadacitinib from Oct 2021, and an IL-23 inhibitor (IL-23i, guselkumab) was subsidized from July 2021.ObjectivesThe aim of this analysis was to describe the changing patterns of b/tsDMARD use for the treatment of PsA in real-world practice in Australia.MethodsDeidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record during the routine consultation1. Data from patients >18 years with a physician diagnosis of PsA who were prescribed a b/tsDMARD between Jan-2007 and Sept-2021 were included in the analysis. The software program Tableau was used to display the data.ResultsAt Sept 2021, 6,150 (38% of the total) patients with PsA in the OPAL dataset were prescribed b/tsDMARDs. Of these patients, 3741 (61%) were currently prescribed a TNFi, 1503 (24%) an IL-17Ai, 556 (9%) a JAKi, 222 (4%) an IL-12/23i and 134 patients (2%) an IL-23i. Over time, the 1st line TNFi initiations have decreased from 79.5% in 2018 to 65.2% in 2021. Conversely, 1st line IL-17Ai initiations have increased from 14.4% in 2018 to 22.2% in 2021. In 2021, TNFi accounted for 53.4% of 2^nd line initiations and 38.2% of 3^rd line initiations. IL-17Ai accounted for 30.4% of 2^nd and 37.0% of 3^rd line initiations and JAKi accounted for 10.5% of 2^nd line and 14.2% of 3^rd line initiations. In the 3 months that IL-23i has been subsidised, this MOA was the most initiated agent for patients who had been treated with more than two prior b/tsDMARDs. In 2021, 52.1% of patients switching from a 1st line TNFi switched to an alternative TNFi, 33.3% switched to an IL-17Ai and 11.3% switched to a JAKi in 2^nd line. Of those switching from a 1^st line IL-17Ai, 59.6% initiated a TNFi, 21.2% switched to an alternative IL-17Ai and 11.5% switched to a JAKi.ConclusionThe patterns of b/tsDMARD utilisation for the treatment of PsA, when the choice of agent is at the discretion of the rheumatologist, remains dynamic and is evolving as new MOAs become available. TNFi remains the most prescribed b/tsDMARD for first line therapy. However an increase in first line use of alternative MOAs has been observed. TNFi cycling remains a commonly utilised real world treatment strategy but appears to be declining as new MOAs become available.References[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheumatol. Sep-Oct 2020;38(5):874-880.Figure 1.Percentage of patients initiating b/tsDMARDs by year and line of therapy.AcknowledgementsThe authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.Disclosure of InterestsPeter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, Sabina Ciciriello: None declared, Gene-Siew Ngian: None declared, Juan Aw: None declared, Barry Kane: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD