OBJECTIVES: Due to the lack of head-to-head comparisons, this study aims to compare the risk of respiratory tract infections (RTIs) associated with individual agents and their respective drug classes in Psoriatic Arthritis (PsA) based on randomized controlled trials (RCTs).

METHODS: Expanding on our prior study that searched from data inception to March 2021, we now extended our search period up to October 2023 on Medline, PubMed, Embase, Scopus, Cochrane Central, and clinicaltrials.gov for phase III or IV RCTs that used biologics or targeted synthetics antirheumatic agents for patients aged >=18 with PsA and reported safety data on RTIs. RTIs were identified during the randomized-controlled period and defined as any reported upper and lower RTIs, regardless of the severity. Bayesian network meta-analyses with random-effect models were used to compare different agents or drug classes. We reported odds ratios (OR) and 95% credible intervals (95%Crl) for pairwise comparisons. The surface under the cumulative ranking curve (SUCRA) was used to report the relative ranking of each agent and drug class.

RESULTS: This updated review newly identified 8 RCTs. Combined with our previous work, a total of 40 RCTs (n=18,897) with 17 interventions (9 drug classes) were included and 2,822 (14.9%) events of RTIs were observed. At the agent-level, abatacept had the lowest RTIs risks (SUCRA=93.47). Drugs that showed higher risk of RTIs compared to placebo included upadacitinib (OR=1.39, 95%Crl=1.01-1.93), apremilast (OR=1.60, 95%Crl=1.66-2.17), and bimekizumab (OR=1.85, 95%Crl=1.21-2.93). At the class-level, selective co-simulation modulator was the safest class treating PsA (SUCRA=96.18). As compared to placebo, Janus kinase inhibitors (OR=1.41, 95%Crl=1.08-1.84) and phosphodiesterase-4 inhibitors (OR=1.59, 95%Crl=1.16-2.23) showed significantly higher risks of RTIs.

CONCLUSIONS: Our findings suggest that abatacept had lowest risks of RTIs for patients with PsA. However, further analyses are needed to evaluate the severity and type of RTIs associated with current treatments.