# Cycling or Swapping in Spondyloarthritis? Current Knowledge

## TL;DR

This review compares cycling and swapping therapies in Psoriatic arthritis and axial spondyloarthritis, finding both strategies equally effective but with potential differences based on patient characteristics.

## Contribution

The paper provides a critical review of cycling versus swapping therapies in PsA and axSpA, highlighting patient-specific factors that may influence treatment outcomes.

## Key findings

- For PsA, cycling and swapping therapies are equally effective, though results may vary by drug and patient characteristics.
- In AxSpA, switching to a second TNFi is reasonable, but treatment effectiveness tends to decline.
- Switching to a different mechanism of action is a valid strategy for secondary non-responders in both conditions.

## Abstract

Psoriatic arthritis (PsA) and axial Spondyloarthritis (axSpA) share some common therapeutic options, namely TNF-inhibitors, anti-IL-17 and JAK-inhibitors. Despite the wealth of choices, often patients do not respond to the first b/tsDMARDs, but they have to switch to another one, either of the same therapeutic category (cycling) or of another (swapping). Which of the abovementioned strategies is better is ill-defined thus far. In this narrative review, we aimed to critically present the relevant literature. PubMed was searched from inception to June 2025 using the following keywords: “Psoriatic arthritis” OR “axial spondyloarthritis” OR “ankylosing spondylitis” OR “non-radiographic axial spondyloarthritis” AND “cycling” OR “swapping” or “switching”. Only studies enrolling adult population were included, while non-English literature was excluded. For PsA, it seems that both cycling and swapping are equally effective, although this might not be the case for all b/tsDMARDs and/or for all patients (e.g. there might be gender differences). For AxSpA, switching to a second TNFi is reasonable, however, treatment effectiveness generally declines. For secondary non-responders, switching to a different mechanism of action seems to be valid strategy. Conclusively, both cycling and swapping strategies appear to be equally successful in PsA and AxSpA. Characteristics, like gender, might affect the efficacy of the one versus the other strategy. In both cases, assessment of the risk factors is warranted.