Early Intensive Therapy Best for PsA With Poor Prognosis

Study shows combination csDMARDs or early TNFi therapy superior to standard step-up care for moderate-severe psoriatic arthritis.

Mar. 13, 2026 at 11:03am

Got story updates? Submit your updates here. ›

A study from the UK found that early intensive treatment with a combination of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or 6 months of TNF inhibitor (TNFi) therapy was superior to standard step-up care for patients with moderate-to-severe psoriatic arthritis (PsA) who had at least one poor prognostic factor. The primary endpoint of mean PsA Disease Activity Score (PASDAS) at 24 weeks was significantly better in both intensive therapy groups compared to standard care, and the early TNFi group maintained better outcomes at 48 weeks.

Why it matters

This study provides evidence that using more aggressive, early treatment approaches can lead to better long-term outcomes for PsA patients at high risk of disease progression. The findings challenge the traditional 'step-up' approach and suggest that rheumatologists should consider starting combination csDMARDs or TNFi therapy upfront for PsA patients with poor prognostic factors.

The details

The three-arm, randomized SPEED study compared standard step-up therapy (starting with methotrexate) to a combination csDMARD regimen (methotrexate plus either sulfasalazine or leflunomide) and early TNFi induction therapy (adalimumab plus methotrexate) in 192 PsA patients. At 24 weeks, both intensive therapy groups showed statistically significant improvements in the primary endpoint of mean PASDAS compared to standard care. There was no difference between the two intensive groups. For the secondary outcome of achieving a PASDAS 'good response' at 24 weeks, 31.2% of the combination csDMARD group and 45.3% of the early TNFi group met this target, compared to only 8% in the standard care group. At 48 weeks, the early TNFi group maintained a significant advantage over standard care on both continuous PASDAS and the binary 'good response' outcome, despite being off the TNFi for 6 months.

  • The SPEED study was first presented at the European Alliance of Associations for Rheumatology (EULAR) 2025 Annual Meeting.
  • The study results were highlighted as one of last year's notable studies on PsA at the Rheumatology Winter Clinical Symposium (RWCS) 2026 in Maui, Hawaii.

The players

Arthur Kavanaugh, MD

Professor of medicine at the University of California, San Diego School of Medicine and co-leader of the RWCS 'year in review' session on PsA.

Laura Coates, MBChB, PhD

Lead investigator of the SPEED study and an NIHR research professor at the University of Oxford.

National Institute for Health Research (NIHR)

The main sponsor of the SPEED trial, with some additional support from AbbVie.

MONITOR-PsA

A UK-based cohort of treatment-naive PsA patients at diagnosis that was used to recruit participants for the SPEED trial.

Got photos? Submit your photos here. ›

What they’re saying

“I think this really makes the case that you should use a TNF inhibitor early on, and if you can't, you should use a combo csDMARD, because in the step-up group, only 8% of people had a PASDAS good response. And this is out at 6 months.”

— Arthur Kavanaugh, MD, Professor of medicine (Medscape Medical News)

“There was numerically a bit of a difference between the combination group and standard care, but at 48 weeks they're starting to balance out a bit more. There was a significant difference in favor of the TNFi, and that's despite the fact that by week 48 they've been off the TNF inhibitor [for 6 months].”

— Laura Coates, MBChB, PhD, Lead investigator of the SPEED study (Medscape Medical News)

What’s next

Coates and other researchers are currently combining data from SPEED and prior studies that compared treatments but did not select for poor prognosis, in order to look more at which patients benefit the most from early intensive treatment and provide more detail on how best to select patients.

The takeaway

This study provides strong evidence that using early, intensive treatment approaches such as combination csDMARDs or TNF inhibitors can lead to significantly better long-term outcomes for psoriatic arthritis patients at high risk of disease progression, challenging the traditional 'step-up' treatment paradigm.