Patrick-Pascal Strunz ¹ Matthias Englbrecht ² Linus M. Risser ³ Torsten Witte ³ Matthias Fröhlich ¹ Marc Schmalzing ¹ Michael Gernert ¹ Astrid Schmieder ⁴ Peter Bartz-Bazzanella ^5,6 Cay von der Decken ^5,6,7 Kirsten Karberg ⁸ Georg Gauler ⁹ Patrick Wurth ⁹ Susanna Spaethling-Mestekemper ¹⁰ Christoph Kuhn ¹¹ Wolfgang Vorbrüggen ⁷ Johannes Heck ¹² Martin Welcker ^13,7 Stefan Kleinert ^1,14*

• ¹ Rheumatology/ Clinical Immunology, Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
• ² Independent researcher, Greven, Germany
• ³ Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Lower Saxony, Germany
• ⁴ Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, Würzburg, Germany
• ⁵ Clinic for Internal Rheumatology, Rhein-Maas-Clinic, Würselen, Germany
• ⁶ Medical Care Center for Rheumatology, Stolberg, Germany
• ⁷ Association for the Promotion of Rheumatology e.V, Würselen, Germany
• ⁸ Rheumatological Care Center Steglitz, Berlin, Germany
• ⁹ Independent researcher, Osnabrück, Germany
• ¹⁰ Rheumapraxis München, München, Germany
• ¹¹ Praxis für Rheumatologie, Karlsruhe, Baden-Württemberg, Germany
• ¹² Institute for Clinical Pharmacology, Hannover Medical School, Hanover, Lower Saxony, Germany
• ¹³ Medizinisches Versorgungszentrum für Rheumatologie Dr. M. Welcker GmbH, Planegg, Germany
• ¹⁴ Praxisgemeinschaft Rheumatologie-Nephrologie, Erlange, Germany

Objective: Treatment options with disease-modifying antirheumatic drugs (DMARDs) for psoriatic arthritis (PsA) have evolved over recent years. In addition to Janus kinase inhibitors (JAKi), four classes of biologic DMARDs (bDMARDs; interleukin [IL]-23 inhibitors [IL-23i], IL-12/23 inhibitors [IL-12/23i], tumor necrosis factor inhibitors [TNFi], and IL-17 inhibitors [IL-17i]) are currently approved for moderate to severe PsA treatment. There is minimal evidence of the persistence of these drugs among PsA outpatients in a real-world scenario during the period following the approval of JAKi. Therefore, we aimed to analyze the drug survival rates of biologic and JAKi therapies among German PsA outpatients during routine clinical care. Methods: We retrospectively analyzed PsA patients with a new prescription for a biologic or JAKi in the RHADAR database between January 2015 and October 2023. Kaplan-Meier Curves and Cox regression modelling were used to compare drug survival rates. Results: 1352 new prescriptions with bDMARDs (IL-12/23i [n=50], IL-23i [n=31], TNFi [n=774], IL-17i [n=360]) or JAKi (n=137) were identified. The 5-year drug survival rate was 67.8% for IL-17i, 62.3% for TNFi, 53.3% for JAKi, and 46.0% for IL-12/23i. Discontinuation probabilities for JAKi and IL-12/23i were significantly higher compared with TNFi (JAKi hazard ratio [HR] 1.66, [95% CI 1.23-2.24], p=0.001; IL-12/23i HR 1.54, [95% CI 1.02-2.33], p=0.042) and IL-17i (JAKi HR 1.77, [95% CI 1.27-2.47], p=0.001; IL-12/23i HR 1.64, [95% CI 1.06-2.55], p=0.027). JAKi-treated patients had more severe disease and more osteoarthritis (OA) compared to TNFi and more OA compared to IL-17i. Conclusions: German PsA outpatients might persist longer with TNFi and IL-17i compared with IL-12/23i or JAKi. For TNFi, differences in subgroup characteristics and comorbidities (OA) may have affected drug survival rates. For IL-17i, the longer drug survival might not only be related to less OA compared to JAKi and, therefore, might be affected by other factors.