Comparative treatment persistence of upadacitinib vs. tofacitinib in psoriatic arthritis: a multicenter observational study from the BIRRA cohort

Background: Real-world comparative data on treatment persistence of upadacitinib and tofacitinib in psoriatic arthritis remain limited. Because persistence reflects treatment durability, tolerability, and perceived benefit in routine practice, it may serve as a pragmatic measure of real-world effectiveness. Objective: This study aimed to compare real-world treatment persistence between upadacitinib and tofacitinib in patients with psoriatic arthritis and to identify predictors of treatment discontinuation using data from the Italian multicenter BIRRA cohort. Methods: In this retrospective, multicenter, observational study, PsA patients treated with UPA and/or TOFA were enrolled from 34 rheumatology centers. Baseline demographics, treatment details, and disease activity (DAPSA) were collected. Treatment persistence was evaluated using Kaplan-Meier survival analysis. Cox proportional hazards models identified predictors of discontinuation, including sex, age, treatment line, prescription year, concomitant csDMARDs/steroids, PsA subtype (peripheral, axial, or mixed), and prior or current JAK inhibitor (JAKi) use. Results: Among 181 enrolled patients (UPA n = 124; TOFA n = 57), retention rates at 6, 12, and 18 months were 86%, 68%, and 54% for UPA and 78%, 60%, and 60% for TOFA (p = 0.7). Concomitant csDMARD therapy (HR: 1.92; 95% CI: 1.04– 3.54; p = 0.037) and later-line treatment (HR: 1.17; 95% CI: 1.01–1.35; p = 0.034) were independently associated with higher discontinuation risk. No statistically significant differences were observed between the two JAK inhibitors. Conclusion: UPA demonstrated a slightly longer persistence than TOFA, though the difference was not statistically significant after adjustment. Concomitant csDMARDs and later treatment lines significantly reduced persistence. These results suggest that PsA treatment retention may be influenced more by patient- and treatment-related factors than by the specific JAK inhibitor prescribed.