1.1 Ixekizumab alone, or with methotrexate, is recommended as an option for treating active psoriatic arthritis in adults, only if:
it is used as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis (recommendations 1.1 and 1.2) or
the person has had a tumour necrosis factor (TNF)-alpha inhibitor but their disease has not responded within the first 12 weeks or has stopped responding after the first 12 weeks or
TNF-alpha inhibitors are contraindicated but would otherwise be considered (as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis).
Ixekizumab is only recommended if the company provides it according to the commercial arrangement.
1.2 Assess the response to ixekizumab after 16 weeks of treatment. Only continue treatment if there is clear evidence of response, defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria. People whose disease has a Psoriasis Area and Severity Index (PASI) 75 response but whose PsARC response does not justify continuing treatment should be assessed by a dermatologist, to determine whether continuing treatment is appropriate based on skin response (as described in NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis, recommendation 1.3).
1.3 When using the PsARC, healthcare professionals should take into account any physical, sensory or learning disabilities or communication difficulties that could affect a person's responses to components of the PsARC and make any adjustments they consider appropriate.
1.4 When using the PASI, healthcare professionals should take into account skin colour and how this could affect the PASI score, and make the clinical adjustments they consider appropriate.
1.5 These recommendations are not intended to affect treatment with ixekizumab that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Why the committee made these recommendations
Ixekizumab is a biological therapy, several of which are already recommended by NICE for treating psoriatic arthritis. Clinical trial evidence shows that ixekizumab is more effective than placebo at treating joint and skin symptoms. An indirect comparison suggests that ixekizumab is likely to be as effective at improving symptoms as some of the current treatments used in the NHS for psoriatic arthritis.
The cost-effectiveness estimates show that for some groups of people with psoriatic arthritis, ixekizumab is the most cost-effective treatment option. For other groups, the difference in health benefits between ixekizumab and the most cost-effective treatment is very small. Overall, the cost effectiveness of ixekizumab is acceptable when it is used after 2 disease-modifying anti-rheumatic drugs, as the first biological therapy, or after treatment with a TNF‑alpha inhibitor. Therefore, it can be recommended.