Epidemiology of Psoriasis and Psoriatic Arthritis in Italy—a Systematic Review

Short-term efficacy of tildrakizumab on difficult-to-treat areas: a real-world experience

BACKGROUND

Novel biologics targeting the IL23/T-17 axis, such as tildrakizumab, have been developed to treat psoriasis. There is limited evidence on the use of tildrakizumab for the treatment of psoriasis in difficult-to-treat areas.

OBJECTIVE

Our aim was to evaluate the short-term efficacy and safety of tildrakizumab in patients with moderate-to-severe psoriasis and with the involvement of difficult-to-treat areas.

METHODS

A multicentric retrospective study was conducted on patients who initiated tildrakizumab between July 2022 and July 2023. Psoriasis Area and Severity Index (PASI), Psoriasis Scalp Severity Index (PSSI), Palmoplantar Psoriasis Area and Severity Index (ppPASI), and Nail Psoriasis Severity Index (NAPSI) were measured at baseline and after 16 weeks. The percentages of achieving a PASI75, PASI90, or PASI100 response were assessed. Dermatology Life Quality Index (DLQI) and Itch Visual Analog Scale (VAS) were measured simultaneously. Data about potential safety issues and adverse events were collected.

RESULTS

A total of 76 patients were included, and 59 (77.6%) were affected by psoriasis localized to the scalp (n = 32), palmoplantar locations (n = 13), or nails (n = 14). The mean PASI score decreased from 16.5 ± 9.8 at baseline to 1.9 ± 1.6 after 16 weeks. Tildrakizumab treatment resulted in the improvement of PSSI (19.9 ± 10.7 to 2.7 ± 4.2), ppPASI (15.4 ± 6.9 to 1.9 ± 2.3), and NAPSI (20.3 ± 16.9 to 7.6 ± 10.8) from baseline to 16 weeks, respectively. DLQI and Itch VAS also showed marked improvement.

CONCLUSIONS

Tildrakizumab is a valuable option for treating difficult-to-treat psoriasis and pruritus, with rapid onset of action.

Risankizumab Versus Secukinumab: A Real-World Efficacy and Cost per Responder Comparison in Patients With Psoriasis in Italy

INTRODUCTION

Risankizumab and secukinumab are effective treatment options for patients with moderate to severe psoriasis.

OBJECTIVES

We sought to estimate the efficacy and the cost per responder of risankizumab and secukinumab by comparing these two drugs in a real-life setting.

METHODS

A multicentric retrospective study was conducted in patients from the Lazio region of Italy affected by moderate-to-severe psoriasis who initiated risankizumab or secukinumab between September 2020 to September 2022. Psoriasis Area and Severity Index (PASI) was measured at baseline and after 16, 52, and 78 weeks. Clinical responses were evaluated by PASI90 and PASI100 responses at the same timepoints. The cost per responder at week 16 and 52 was adopted as a cost-effectiveness indicator.

RESULTS

Included were 141 patients, 74 (52.5%) treated with risankizumab and 67 (47.5%) treated with secukinumab. PASI90 responses in risankizumab-treated patients were higher than those observed in patients treated with secukinumab at both weeks 16 and 52 (79.7% versus 64.2% (P = 0.041) and 98.6% versus 83.6% (P = 0.003), respectively). Risankizumab also showed superior PASI100 rates at week 52 (85.5% versus 65.6%, P = 0.009). No statistically significant differences were observed in PASI90 and PASI100 rates between the 2 groups at week 78. The cost per PASI90 and PASI100 responder for risankizumab was lower at both weeks 16 (€5833.66 and €8394.78, compared to €8747.18 and €10746.53 for secukinumab) and 52 (€11798.90 and €13598.73 vs €15347.70 and €19568.31, respectively).

CONCLUSIONS

Risankizumab showed superior efficacy than secukinumab and a lower cost per responder.

Impact of Psoriasis on Pregnancy Desire and Possible Consequences on Fertility

INTRODUCTION

Approximately half of patients affected by psoriasis are women, and the management of female patients of childbearing age is an under-investigated topic. Some studies have shown a significant decrease in births in psoriatic patients due to intimacy and pregnancy avoidance and to potential birth complications.

OBJECTIVES

We sought to evaluate data on reproductive health in a cohort of female patients, to compare them with similar data in the general population and to assess the impact of psoriasis, especially genital psoriasis, on pregnancy desire and the prevalence of psoriasis in the children of patients with psoriasis.

METHODS

This retrospective observational study involved adult female patients with a diagnosis of psoriasis made during or before childbearing age. The enrolled patients were asked questions concerning fertility and previous pregnancies in relation to their dermatologic disease.

RESULTS

Of 100 women enrolled, 73 reported a history of pregnancy, for a total of 170 pregnancies. The average number of pregnancies to term and the average number of children per woman (1.2 ± 1) were lower than the national average. The percentage of miscarriages was 18.2%, higher than the national average; in particular, women with psoriatic arthritis had a greater percentage of miscarriages (27.4%). During the pregnancies, psoriasis was mainly stable (36.1%) or improved (29.2%), even though most patients (91.5%) did not follow any treatment.

CONCLUSIONS

Psoriasis impacts pregnancy desire and course. The management of psoriasis in women of childbearing age is crucial to minimize its burden on this vulnerable population.

Relationship of psoriatic arthritis with nail and scalp involvement in Turkish psoriasis patients: Multicentered cross-sectional study

Psoriasis is a common multisystem inflammatory disease, and arthritis is an essential component of the disorder, requiring early diagnosis and prompt treatment for successful management. In this study, we aimed to investigate the relationship between nail and scalp involvement and other covariates with psoriatic arthritis (PsA). This cross-sectional study, conducted from June 2021 through December 2021, included 763 patients from 11 different centers in Turkey. The severity of involvement was evaluated using psoriasis area severity index (PASI), nail psoriasis severity index (NAPSI), and psoriasis scalp severity index (PSSI) scores. Predictors for PsA were evaluated using univariate and multivariate logistic regression models. PsA (n = 155, 21.5%) was significantly more common in patients having a family history of psoriasis (43.2% vs 30.9%, P = .004), nail involvement (68.4% vs 52.3%, P < .001), and coexistence of nail and scalp involvement (53.7% vs 39.6%, P = .002). Furthermore, patients with PsA had considerably higher PASI (7 vs 5.6, P = .006), NAPSI (5 vs 2, P < .001), and PSSI scores (7 vs 4, P = .002) and longer disease duration (months) (126 vs 108, P = .009). In multivariate analysis, female gender [OR: 3.01, 95% CI (1.861-4.880), P < .001], nail involvement [OR: 2.06, 95% CI (1.293-3.302), P = .002)], and body mass index (BMI) [OR: 1.06, 95% CI (1.017-1.100), P = .005] were identified as independent predictors for PsA. Female gender, nail involvement, and high BMI are significant predictors for PsA and warrant detailed rheumatological assessment. Notably, being female is the strongest predictor of increased risk of PsA in our survey. Scalp involvement appears not to be associated with PsA. Also, the presence of PsA seems related to a more severe skin involvement phenotype.

Global burden and future trends in psoriasis epidemiology: insights from the global burden of disease study 2019 and predictions to 2030

BACKGROUND

Millions of people worldwide are affected by psoriasis, one of the most prevalent skin conditions. Currently, there is a lack of high-quality epidemiological reports on psoriasis.

OBJECTIVE

This study aimed to reveal trends in psoriasis epidemiology in 1990-2019.

METHODS

Using data from the GBD study 2019, we examined psoriasis epidemiology globally and across regions defined by the social-demographic index (SDI). Trends in incidence, prevalence, and disability-adjusted life year (DALY) rates were assessed using estimated annual percentage changes (EAPC)s. Age-period-cohort analysis examined risk variations, and decomposition analysis identified factors impacting the psoriasis burden. A Bayesian Age-Period-Cohort model predicted future incidence. Frontier analysis associated psoriasis outcomes with socio-demographic development.

RESULTS

In 2019, the global psoriasis burden included 4,622,594 incidence, 40,805,386 prevalence, and 3,505,736 DALY cases. Despite variations in SDI regions, the overall trend showed a decline in psoriasis rates from 1990 to 2019 (EAPC = - 0.76). The age-specific analysis indicated that the highest incidence of psoriasis was observed among individuals aged 40-64 years (global, 1,606,429). Epidemiological shifts contributed negatively to global incidence and DALYs by - 80.52% and - 103.06%, respectively. Countries like San Marino and Spain displayed the highest effective differences in the decomposition analysis. By 2030, while incidence cases per 10,000 might rise (487.36, 423.62 to 551.10), age-standardized incidence rates per 100,000 were predicted to decline (53.67, 0.00 to 259.99).

CONCLUSION

This research revealed a global decline in psoriasis incidence rate from 1990 to 2019, with predictions suggesting this trend continues through 2030. Geographic disparities underscore the importance of tailored healthcare policies.

Generating detailed intercellular communication patterns in psoriasis at the single-cell level using social networking, pattern recognition, and manifold learning methods to optimize treatment strategies

Psoriasis, a complex and recurrent chronic inflammatory skin disease involving various inflammatory cell types, requires effective cell communication to maintain the homeostatic balance of inflammation. However, patterns of communication at the single-cell level have not been systematically investigated. In this study, we employed social network analysis tools, pattern recognition, and manifold learning to compare molecular communication features between psoriasis cells and normal skin cells. Utilizing a process that facilitates the discovery of cell type-specific regulons, we analyzed internal regulatory networks among different cells in psoriasis. Advanced techniques for the quantitative detection of non-targeted proteins in pathological tissue sections were employed to demonstrate protein expression. Our findings revealed a synergistic interplay among the communication signals of immune cells in psoriasis. B-cells were activated, while Langerhans cells shifted into the primary signaling output mode to fulfill antigen presentation, mediating T-cell immunity. In contrast to normal skin cells, psoriasis cells shut down numerous signaling pathways, influencing the balance of skin cell renewal and differentiation. Additionally, we identified a significant number of active cell type-specific regulons of resident immune cells around the hair follicle. This study unveiled the molecular communication features of the hair follicle cell-psoriasis axis, showcasing its potential for therapeutic targeting at the single-cell level. By elucidating the pattern of immune cell communication in psoriasis and identifying new molecular features of the hair follicle cell-psoriasis axis, our findings present innovative strategies for drug targeting to enhance psoriasis treatment.

Estimation of patients with psoriasis potentially eligible and currently untreated with biological drugs in Italy

BACKGROUND

Psoriasis (PSO) patients can benefit from the growing availability of novel biological agents, that are often underused or discontinued. This real-world analysis estimated PSO patients potentially eligible and currently untreated with biologics in Italy.

METHODS

An observational analysis was performed on administrative databases of a pool of healthcare entities, covering 11.3% of Italian population. During the inclusion period (2010- 2020), patients were identified by: 1) at least one prescription of topical drugs for PSO; or 2) active exemption for PSO; or 3) at least one PSO hospital discharge diagnosis. The index-date was the first PSO identification across inclusion period. Eligibility for biologics was evaluated prior to index-date (characterization period) through two not-mutually exclusive criteria: Criterion A, failure of at least one systemic treatment, and/or Criterion B, onset of psoriatic arthritis (PsA). Data were re-proportioned to the Italian population.

RESULTS

The study sample showed a PSO prevalence of 2%. Projection to 2020 national population (N=59,236.213) estimated 1.43 million Italian patients affected by PSO: 95% treated with conventional therapies, 4% with biologics, and 1% untreated. Among those non-treated with biologics, 3.8% of overall PSO patients met one or both eligibility criteria for biologics, specifically 25% met criterion A (failure to conventional treatments), 68% criterion B (PsA co-diagnosis), and 7% met both. About half of them had 1 or 2 comorbidities and 30% above 3.

CONCLUSIONS

These findings from real clinical practice estimated about 4% PSO patients potentially eligible for biologics, but still untreated, with nearly one-third exhibiting a complex comorbidity profile.

Real-World Apremilast Use for Treatment of Plaque Psoriasis in Italy: Patient Perspective, Characteristics, and Clinical Outcomes from the DARWIN Study

INTRODUCTION

While several European studies have reported real-world apremilast use, patient-perceived benefits, and treatment satisfaction, local reimbursement criteria for apremilast vary and data from Italy are limited.

METHODS

The cross-sectional DARWIN study enrolled consecutive patients who had initiated apremilast for plaque psoriasis 6 (± 1) months prior to enrolment at a single visit across 24 Italian dermatological sites. Disease severity was assessed using body surface area (BSA) and Physician Global Assessment (PGA). Patient-reported outcomes assessed 6 (± 1) months after apremilast initiation were Dermatology Life Quality Index (DLQI), Patient Benefit Index (PBI), and 9-item Treatment Satisfaction Questionnaire for Medication (TSQM-9).

RESULTS

Of 184 patients enrolled between July 2019 and January 2021, 180 were included in the analysis. At apremilast initiation, median (25th-75th percentile) time since psoriasis diagnosis was 8.6 (3.2-22.2) years; median BSA, 10.0% (5.0-16.0); mean (standard seviation, SD) DLQI total score, 13.5 (8.0). Over half (54.9%) of patients with available data reported psoriasis had a very or extremely large effect on their quality of life (QoL); half reported itching (50.6%) and/or special areas involvement (50.0%). Most (73.9%) had comorbidities and were biologic-naïve (81.5%). The most common reasons for initiating apremilast were lack of efficacy of previous treatment (56.7%) and contraindications to other treatments (44.4%). At 6 (± 1) months, most patients were continuing apremilast and/or reported a Global PBI score ≥ 1 (minimum clinical benefit) (86.1% and 90.0%, respectively); approximately half achieved BSA ≤ 3% and/or DLQI total score ≤ 5 (47.1% and 48.5%); 18.8% achieved PGA = 0; mean (SD) TSQM-9 global treatment satisfaction score was 59.0 (24.8). Apremilast was well tolerated; no new safety signals were identified.

CONCLUSIONS

Patients treated with apremilast for 6 months in Italian clinical practice reported improved QoL, clinically relevant improvements in symptoms, high treatment satisfaction, and high treatment persistence. Our data indicate apremilast is a valuable treatment option for moderate plaque psoriasis.

STUDY REGISTRATION

ClinicalTrials.gov identifier, NCT04031027.

Risankizumab: Daily Practice Experience of High Need Patients

Psoriasis is a chronic inflammatory disease which affects 29.5 million people worldwide and it can negatively impact quality of life, especially when it affects a special localization, such as nails, face, palms and soles, or intertriginous regions. Risankizumab is a humanized monoclonal antibody which targets the p19 subunit of interleukin-23 and it is currently licensed also as systemic therapy for moderate to severe plaque psoriasis. Here, we present eight cases of patients with moderate to severe psoriasis treated with risankizumab with a significant efficacy in the remission of the disease. Our cases represent a real-world clinical setting and provide a valuable adjunct to results obtained in the selected patients usually included in controlled clinical trials. In our cases, risankizumab rapidly improved clinical manifestations and relieved symptoms in patients with moderate to severe psoriasis, regardless of the presence of comorbidities or the location of the plaques in special sites, and without any safety concerns.

Analysis of Drug Utilization in Patients with Psoriasis: A Real-World Retrospective Study Among the Italian Population

Purpose

An Italian real-world retrospective study was conducted in patients with psoriasis (PSO) to evaluate their characteristics, treatment patterns, and biological/targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) drug utilization.

Patients and Methods

The retrospective analysis was carried out on real-world data collected from administrative databases of selected Italian health-departments; the dataset covered approximately 22% of the Italian population. PSO patients (identified by PSO hospitalization, and/or active exemption code and/or a topical anti-psoriatic medication prescription) were included. In prevalent patients identified during 2017-2018-2019-2020, baseline characteristics and treatment patterns were investigated. Moreover, b/tsDMARD drug utilization (focusing on persistence, monthly dosage, and mean duration between prescriptions) was evaluated in bionaïve patients included during 2015 and 2018.

Results

PSO was diagnosed in 241,552 (in 2017), 269,856 (in 2018), 293,905 (in 2019) and 301,639 (in 2020) patients. At the index date, almost 50% of patients had not received systemic medications, and 2% had received biological treatment. Among the b/tsDMARD-treated patients, a decrease in the use of tumour necrosis factor (TNF) inhibitors (60.0-36.4%, from 2017 to 2020) and an increase in the use of interleukin (IL) inhibitors (36.3-50.6%, from 2017 to 2020) were observed. In 2018, the persistence rates of TNF inhibitors and IL inhibitors in bionaïve patients ranged from 60.8-79.7% and 83.3-87.9%, respectively.

Conclusion

This real-world study of PSO drug utilization in Italy showed that a significant number of patients were not treated with systemic medications and only 2% of patients were treated with biologics. An increase in the use of IL inhibitors and a decrease in the prescription of TNF inhibitors over years were found. Patients treated with biologics were highly persistent with treatment. These data provide insight into routine clinical practice for PSO patients in Italy, suggesting that the optimization of treatment for PSO still represents an unmet medical need.

A real-world economic analysis of biologic therapies for psoriatic arthritis in Italy: results of the CHRONOS observational longitudinal study

BACKGROUND

Psoriatic arthritis (PsA) is a chronic, immune-mediated, spondyloarthropathy characterised by musculoskeletal signs and symptoms with associated joint pain and tenderness. The average worldwide PsA prevalence is 133/100,000, while in the Italian population is 90-420/100,000. Traditionally, nonsteroidal anti-inflammatory drugs, glucocorticoid, and disease-modifying antirheumatic drugs have been used in the treatment of PsA. However, for those patients who are not adequately controlled with conventional therapies, the new biologics compounds represent a valid option. Biologic therapies have been shown to be more effective but also more expensive than conventional systemic treatments. Based on the CHRONOS study, the economic analyses presented in this paper aim to assess the annualised direct costs and the cost-per-responder of biologics in a real-world context assuming the Italian National Health System perspective.

METHODS

The economic assessments were carried out on the overall cohort of patients, and on the tumour necrosis factor alpha inhibitors (TNFi) and the secukinumab subgroup, the most prescribed biologic therapies within the CHRONOS study.

RESULTS

The annual economic impact of PsA in the overall group was €12,622, €11,725 in the secukinumab subgroup, and €12,791 in the TNFi subgroup. Biologics absorbed the main expenditure costs in the treatment of PsA accounting for about the 93% of total costs. At 6 months, secukinumab performed better in all the considered outcomes: cost-per-responder according to EULAR DAS28 and ACR50 response criteria were €12,661- €28,975, respectively, while they were €13,356 - €33,368 in the overall cohort and €13,138 - €35,166 in the TNFi subgroup. At 12 months secukinumab remained the subgroup with the lowest cost-per-responder ratio in EULAR DAS28 and ACR50 response criteria, while TNFi subgroup was the lowest one considered the ACR20.

CONCLUSION

Despite some potential methodological limitations, our cost-per-response analysis provides physicians and payers additional insights which can complement the traditional risk-benefit profile assessment and drive treatment decisions.

Treatment Patterns and Pharmacoutilization in Patients Affected by Psoriasis: An Observational Study in an Italian Real-World Setting

BACKGROUND

Real-world data can inform the use of biologics for psoriasis (PSO).

OBJECTIVE

The aim was to evaluate treatment patterns and analyze pharmacoutilization in PSO patients in a real-world Italian setting, with a focus on the biologics most recently introduced.

METHODS

An observational study based on administrative databases was conducted. Patients were included based on PSO diagnosis identified by either discharge diagnosis or exemption code or prescription of anti-psoriatic topical drugs (proxy of diagnosis). To describe patient characteristics and treatment patterns using the most up-to-date data, two different approaches were used: a cross-sectional study performed during 2016-2018, and a longitudinal study conducted with patients who received their first biological/targeted synthetic drugs (naïve patients) in 2014 and 2017 (the inclusion periods).

RESULTS

During 2016-2018, the number of prevalent patients diagnosed with PSO was 194,054 (2016), 210,830 (2017), and 225,171 (2018). The percentage of patients receiving biologics or targeted synthetic agents ranged from 1.5 to 2.1%. Among them, naïve patients receiving interleukin (IL) inhibitors increased from 37.5% (2016) to 69.4% (2018), while those receiving anti-tumor necrosis factor (anti-TNF) decreased from 62.5% (2016) to 30.6% (2018). The longitudinal analysis included 894 and 1218 naïve patients in 2014 and 2017, respectively, of whom 7.2% (2014) and 6.9% (2017) switched therapy after a mean of 7.1 (2014) and 6.9 (2017) months. Overall, 259 patients were prescribed ixekizumab starting in 2017, of whom 73% were naïve. Ixekizumab was prescribed as monotherapy to 52.5%.

CONCLUSIONS

The proportion of patients receiving biologics appeared constant over the years, with an increasing number of naïve patients being prescribed IL-17 inhibitors. Ixekizumab patients were mostly naïve.

Annoying Psoriasis and Atopic Dermatitis: A Narrative Review

Skin is an important organ that mainly functions as a barrier. Skin diseases can damage a person's self-confidence and reduce their willingness to socialize, as well as their social behavior and willingness. When the skin appearance is abnormal, in addition to affecting the quality of life, it often leads to personal, social, and psychological dysfunction and even induces depression. Psoriasis and atopic dermatitis are common chronic skin diseases. Their prevalence in the world is 3-10%, and there is an increasing trend year by year. These congenital or acquired factors cause the dysfunction of the immune system and then destroy the barrier function of the skin. Because these patients are flooded with a variety of inflammatory mediators, this causes skin cells to be in chronic inflammation. Therefore, psoriasis and atopic dermatitis are also considered systemic chronic inflammatory diseases. In the healthcare systems of developed countries, it is unavoidable to spend high costs to relieve symptoms of psoriasis and atopic dermatitis patients, because psoriasis and atopic dermatitis have a great influence on individuals and society. Giving a lot of attention and developing effective treatment methods are the topics that the medical community must work on together. Therefore, we used a narrative review manuscript to discuss pathogenesis, clinical classification, incidence, and treatment options, including topical medication, systemic therapeutics, immunosuppressive medication for psoriasis, and atopic dermatitis, as well as also comparing the differences between these two diseases. We look forward to providing readers with comprehensive information on psoriasis and atopic dermatitis through this review article.

Methotrexate in the therapeutic pathway of patients with psoriasis. Analysis of clinical practice data and comparison with guidelines

Psoriasis is an inflammatory skin disease with a chronic-relapsing course. It is estimated that the prevalence in Italy is 3%. An adequate model of taking care of the patient with psoriasis allows the patient to benefit from the most suitable treatment option for his health needs. In this position statement the observations, criticalities and proposals for improvement of the Pso-Path Working Group, composed by health economists, clinicians and patients, on the diagnostic-therapeutic pathway of the patient with psoriasis have been collected. In particular, the deviation of clinical practice from the current Guidelines for the management of patients with psoriasis, which recommend the use of biologic drugs in case of non-response, intolerance or contraindication to Methotrexate or Cyclosporine, was evaluated. A Working Group was convened whose participants were asked to express their thoughts on the diagnostic and therapeutic pathway of the patient with psoriasis, bringing out critical elements and proposals for improvement, based on their experiences. This position statement summarizes the experiences and consensus between clinicians and patients on actions to optimize the management of patients with psoriasis undergoing biological treatment. Compared to the epidemiological data currently available, it is believed that only a small percentage of patients with psoriasis are treated with systemic drugs. The perception of clinicians, according to their experience, confirms the data emerging from the National Report “National Observatory on the Use of Medicines” (Osmed) compiled by AIFA in 2015, according to which more than 77% of patients with psoriasis are started to treatment with biological drugs without a previous use of Methotrexate or Cyclosporine for at least 3 months. The Pso-Path Working Group concluded that it would be desirable to incentivize, through the formalization of regional guidelines, the creation of a network system that promotes not only a greater awareness, at the territorial level, of the importance and impact of the disease and the possible paths, but also the collaboration and connection between all the actors involved in the overall care of the patient.

Costo per responder del metotrexato rispetto ad altre terapie in pazienti con psoriasi a placche da moderata a grave in Italia

Objective:

Conventional synthetic disease modifying antirheumatic drugs (csDMARDs) were recommended in 2019 as first line therapy from Italian Medicines Agency (AIFA) for the treatment of moderate to severe psoriasis. Updated local guidelines recommended methotrexate (MTX) as the drug of first choice. Nevertheless, MTX is reported by AIFA to be underused. Since no study evaluated jointly the first-line efficacy and costs of the most widely used biologic drugs (adalimumab, etanercept, secukinumab and ustekinumab) and methotrexate in Italy, a cost per responder (CPR) analysis was performed.

Methods:

A CPR model was developed based on efficacy data from a published Cochrane network meta-analysis. Drug costs included in the model were estimated based on average regional tender prices. The primary analysis assessed the CPR of both Psoriasis Area and Severity Index (PASI) 90 at weeks 12 and 52. A secondary analysis was conducted considering PASI 75. For methotrexate, both an average dosage of 13.4 mg, estimated by an expert panel, and a dosage of 15 mg reported in European guidelines were considered.

Results:

At weeks 12 and 52, the costs per responder PASI 90 were lower for methotrexate 13.4 mg compared to the most widely used biologics in Italy, € 566.71 and € 2,455.72 respectively. Methotrexate also showed a lowest CPR both at 12 and 52 weeks, € 529.95 and € 2,296.47 respectively, in the secondary analysis.

Conclusions:

The analysis showed a lower cost per responder for methotrexate than for adalimumab, etanercept, secukinumab and ustekinumab. For healthcare budget holders, this means using the saved resources to treat more patients.

Nail Psoriasis and Quality-of-Life Measurement in Clinical Trials: Call for the Use of Nail-Specific Instruments

Nail involvement is frequent in people with psoriasis. It can considerably impair health-related quality of life (HRQoL) beyond the impairments due to other psoriasis symptoms, for example, because patients feel ashamed of visible nail defects or because of the functional impairment in manual activities and walking. In clinical trials on nail psoriasis, it is therefore crucial to assess whether the treatment reduces HRQoL impairments that are specific to nail psoriasis. For this purpose, two validated patient questionnaires are available, the Nail Psoriasis Quality of Life Scale (NPQ10) and the Nail Assessment in Psoriasis and Psoriatic Arthritis-Quality of Life (NAPPA-QOL). The ten-item NPQ10 has the advantage of being short and thus quick to administer. The 20-item NAPPA-QOL, in contrast, assesses the different dimensions of HRQoL which is considered a multi-dimensional construct. Yet most randomized controlled trials on nail psoriasis do not evaluate HRQoL improvement. If they do, a number of different instruments are used, most of which are not nail specific. This makes comparison of trial outcomes difficult. Harmonizing the measurement of HRQoL in future clinical trials on nail psoriasis would improve comparability across studies and would also enhance the reliability of meta-analyses.

Real-world evidence of biologic treatments in moderate-severe psoriasis in Italy: Results of the CANOVA (EffeCtiveness of biologic treAtmeNts for plaque psOriasis in Italy: An obserVAtional longitudinal study of real-life clinical practice) study

EffeCtiveness of biologic treAtmeNts for plaque psOriasis in Italy: An obserVAtional (CANOVA) study was aimed at providing real-world evidence of the effectiveness of biologics in Italian patients with moderate-severe psoriasis. It was an observational, retro-prospective cohort study conducted in 17 Italian dermatology clinics. Adult patients with moderate-severe plaque psoriasis, who started a biologic treatment between 24 weeks and 24 months before enrolment, were included. With a follow-up visit at 6 months after enrolment, each patient had at least 12 months of observation. The primary objective was to describe the clinical response rates (PASI 75) after 16/24/52 weeks from biologic treatment start. Secondary outcomes were sustained response, quality of life, and treatment satisfaction. Of the 669 eligible patients (64% males), 52% were naïve to biologics, though a mean duration of psoriasis since first diagnosis of 18.6 years (SD 13.2). The most frequently prescribed biologics were secukinumab (41%), ustekinumab (25%), TNF-inhibitors (22%) and ixekizumab (12%). PASI 75 was achieved by 86% of patients (95% CI: 82%-89%) at 16 weeks, 90% (87%-93%) at 24 weeks, and 91% (89%-94%) at 52 weeks. Patients achieving PASI 90 and PASI 100 at 52 weeks were 75% (71%-79%) and 53% (49%-57%), respectively. Sustained PASI 75 response after 1 year from treatment start was achieved by 78% (74%-82%) of patients. Mean DLQI total score was 2.3 (SD 3.9) at enrollment and decreased at the final visit to 1.8 (3.6). A high level of treatment satisfaction was expressed by patients over the study period. This large real-world study confirms in the clinical practice the good effectiveness and acceptability of biologics in psoriasis patients.

Impact of Body Mass Index on the Efficacy of Biological Therapies in Patients with Psoriasis: A Real-World Study

BACKGROUND

The efficacy of biological therapies used for the treatment of chronic plaque psoriasis can be influenced by numerous variables including  body mass index (BMI).

OBJECTIVE

This study aimed to evaluate the impact of BMI on the short-term and long-term efficacy of biological therapies in clinical practice and to identify the best therapeutic options in obese patients (BMI ≥ 30 kg/m2).

METHODS

A multicentric retrospective study was conducted in patients who initiated a biological therapy during the period January 2006-December 2019. The proportion of patients achieving a 90% improvement of baseline Psoriasis Area and Severity Index at weeks 12 and 24 was calculated also recording the 12- and 24-month drug survival as a measure of long-term efficacy, performing multivariate analyses to assess the impact of different variables.

RESULTS

Five hundred and four patients with psoriasis were included. After 12 and 24 weeks, the proportion of patients achieving a 90% improvement of baseline Psoriasis Area and Severity Index response was higher in patients with a BMI < 30 kg/m2 compared with those with a BMI ≥ 30 kg/m2 [54.90% vs 43.45% (p = 0.014) at week 12 and 66.84% vs 56.55% (p = 0.021) at week 24]. The Kaplan-Meier survival curves showed how obese patients had a higher probability of discontinuation due to a lack or loss of efficacy (p = 0.0192) compared with non-obese patients. The drug survival analysis also showed that BMI negatively affected the drug survival of secukinumab (odds ratio 1.27, p < 0.001) and ustekinumab (odds ratio 1.06, p = 0.050), while the long-term efficacy of adalimumab, etanercept, and ixekizumab was not influenced by BMI.

CONCLUSIONS

Obesity (BMI ≥ 30 kg/m2) negatively affects the clinical response of biological drugs in psoriatic patients, with anti-interleukin drugs being more affected by BMI than anti-tumor necrosis factor drugs.

A real-world economic analysis of biologic therapies for moderate-to-severe plaque psoriasis in Italy: results of the CANOVA observational longitudinal study

BACKGROUND

Psoriasis is a chronic immune-mediated inflammatory skin disease which can also involve joints. It is often associated with burdensome comorbidities which negatively impact prognosis and quality of life (QoL). Biologic agents have been shown to be effective in controlling disease progression, but their use is associated with higher costs compared with traditional systemic treatments. The economic analysis of the CANOVA (EffeCtiveness of biologic treAtmeNts for plaque psOriasis in Italy: an obserVAtional longitudinal study of real-life clinical practice) study aims to assess the costs and cost-effectiveness of biologics in a real-world context in Italy.

METHODS

The annualised overall direct costs of moderate-to-severe plaque psoriasis management, the annualised cost of biologic drugs and the cost per responder in the Italian National Health System perspective were assessed. More specifically, the cost per response and cost per sustained response of the most prescribed biologic therapies for the treatment of moderate-to-severe plaque psoriasis within the CANOVA study were assessed using the Psoriasis Area Severity Index (PASI) at several score levels (75, 90 and 100%).

RESULTS

The most frequently used biologic therapies for plaque psoriasis were secukinumab, ustekinumab, adalimumab originator, and ixekizumab. Cost of biologics was the driver of expenditure, accounting for about 98% of total costs. Adalimumab originator was the biologic with the lowest cost per responder ratio (range: €7848 - €31,378), followed by secukinumab (range: €9015 - €33,419). Ustekinumab (range: €11,689 - €39,280) and ixekizumab (range: €11,092 - €34,289) ranked respectively third and fourth, in terms of cost-effectiveness ratio. As concerns the cost per sustained response analysis, secukinumab showed the lowest value observed (€21,375) over the other options, because of its high response rate (86% vs. 60-80%), which was achieved early in time.

CONCLUSION

Biologic therapy is a valuable asset for the treatment of moderate-to-severe plaque psoriasis. Concomitant assessment of treatment costs against the expected therapeutic response over time can provide physicians and payers additional insights which can complement the traditional risk-benefit profile assessment and drive treatment decisions.

Common Variable Immunodeficiency and Autoimmune Diseases: A Retrospective Study of 95 Adult Patients in a Single Tertiary Care Center

Common variable immunodeficiency (CVID) is the most common clinically significant primary immunodeficiency in adulthood, which presents a broad spectrum of clinical manifestations, often including non-infectious complications in addition to heightened susceptibility to infections. These protean manifestations may significantly complicate the differential diagnosis resulting in diagnostic delay and under-treatment with increased mortality and morbidity. Autoimmunity occurs in up to 30% of CVID patients, and it is an emerging cause of morbidity and mortality in this type of patients. 95 patients (42 males and 53 females) diagnosed with CVID, basing on ESID diagnostic criteria, were enrolled in this retrospective cohort study. Clinical phenotypes were established according to Chapel 2012: i) no other disease-related complications, ii) cytopenias (thrombocytopenia/autoimmune hemolytic anemia/neutropenia), iii) polyclonal lymphoproliferation (granuloma/lymphoid interstitial pneumonitis/persistent unexplained lymphadenopathy), and iv) unexplained persistent enteropathy. Clinical items in the analysis were age, gender, and clinical features. Laboratory data included immunoglobulin (Ig)G, IgM and IgA levels at diagnosis, flow-cytometric analysis of peripheral lymphocytes (CD3+, CD3+CD4+, CD3+CD8+, CD19+, CD4+CD25highCD127low, CD19hiCD21loCD38lo, and follicular T helper cell counts). Comparisons of continuous variables between groups were performed with unpaired t-test, when applicable. 39 patients (41%) showed autoimmune complications. Among them, there were 21 females (53.8%) and 18 males (46.2%). The most prevalent autoimmune manifestations were cytopenias (17.8%), followed by arthritis (11.5%), psoriasis (9.4%), and vitiligo (6.3%). The most common cytopenia was immune thrombocytopenia, reported in 10 out of 95 patients (10.5%), followed by autoimmune hemolytic anemia (n=3, 3.1%) and autoimmune neutropenia (n=3, 3.1%). Other autoimmune complications included thyroiditis, coeliac disease, erythema nodosum, Raynaud’s phenomenon, alopecia, recurring oral ulcers, autoimmune gastritis, and primary biliary cholangitis. There were no statistically significant differences comparing immunoglobulin levels between CVID patients with or without autoimmune manifestations. There was no statistical difference in CD3+, CD8+, CD4+CD25highCD127low T, CD19, CD19hiCD21loCD38lo, and follicular T helper cell counts in CVID patients with or without autoimmune disorders. In conclusion, autoimmune manifestations often affect patients with CVID. Early recognition and tailored treatment of these conditions are pivotal to ensure a better quality of life and the reduction of CVID associated complications.

Secukinumab Exhibits Sustained and Stable Response in Patients with Moderate-to-Severe Psoriasis: Results from the SUPREME Study

Secukinumab, a fully human monoclonal antibody, neutralizes interleukin-17A, a cornerstone cytokine driving the multiple manifestations of psoriasis. This post-hoc analysis of the SUPREME study was performed to determine the sustainability of response to secukinumab in terms of Psoriasis Area and Severity Index (PASI) 90 in patients with moderate-to-severe plaque psoriasis. Based on PASI 90 response at week 16, patients were stratified as PASI 90 responders (PASI90R, n = 337) or non-responders (PASI90NR, n = 72). At week 20, 94.2% (n = 295/313) achieved PASI 90/100 response in PASI90R, with response maintained through week 48 (89.6%, n = 189/211). An increased proportion of patients achieved PASI 90/100 response in PASI90NR (week 20: 29.9%, n = 20/67; week 48: 57.1%, n = 20/35). Overall, 64.4% patients achieved absolute PASI score = 0 at week 24 with response sustained to week 48 (66.9%). Secukinumab showed sustained and stable efficacy in maintaining PASI 90 response in patients with moderate-to-severe plaque psoriasis up to week 48.

Pattern of drug use in patients with psoriatic arthritis in Italy: study in a real-world setting

Background: The aim of this study is to assess treatment patterns and pharmaco-utilization in patients with psoriatic arthritis (PsA) in Italy.Methods: A retrospective analysis using administrative databases of six Local Health Units was performed. All adult patients with PsA diagnosis and ≥1 prescription for biologic/targeted-synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) from January 2010 to March 2017 were included. The date of first b/tsDMARD prescription was defined index-date. Follow-up lasted 1-year post index-date. Patients without b/tsDMARDs prescription pre index-date were defined bionaïve.Results: Of the 1,056 patients included, 33% received adalimumab, 30% etanercept, 10% golimumab, 9% secukinumab, 7% infliximab, 6% ustekinumab, 4% certolizumab, and 1% apremilast. During follow-up, persistence with b/tsDMARDs was observed in 79.8% of patients, 10.8% switched therapies, dose change occurred in 15.8% of patients, 47.4% received an add-on. Among bionaïve patients (n = 591), 67.0% were persistent with b/tsDMARDs, 10.1% switched therapy, 14.5% required a dose change and 45.8% an add-on. Discontinuation was observed in 10.6% of total PsA population and in 24.8% of bionaïve patients.Conclusion: This analysis provided insights on drug utilization patterns for PsA in an Italian real-world setting. Our results show that treatment regimen changes occur in a high proportion of PsA patients.

Assessing the Beneficial Impact of a Patient Support Program in Secukinumab-Treated Patients with Psoriasis in Italy

PURPOSE

For patients with psoriasis, treatment adherence and persistence are fundamental if therapeutic goals are to be met. Patient Support Programs (PSPs) may be used as a support tool to assist patients and health care professionals optimize treatment and improve disease management.

PATIENTS AND METHODS

In Italy, the PSP PSOLife CARE, which began on the 9th of February 2017 and is ongoing, aimed to support patients with psoriasis under therapy with secukinumab (Cosentyx^®). A team of medical professionals including Dermatologists, Psychologists, Nutritionists, and field Nurses provided outpatient treatment as well as remote support via phone calls. Patients had a standard duration in the Program of 6 months. This report analyzes the data of patients who benefited from the Program from February 2017 to August 2020, for a total observation of 42 months.

RESULTS

We provide here a descriptive report on the benefits of participation in the PSOLife CARE Program for patients with psoriasis and medical professionals involved in their care. Throughout their time in the PSOLife CARE Program, patient satisfaction remained consistently high with sustained improvements observed in all aspects of quality of life (ie emotional, social, physical, and economic). Despite exiting from the Program, most patients continued to adhere to secukinumab. Medical professionals also reported positive outcomes on their interactions with patients, with more than half of those surveyed rating the overall quality of the Program as "Outstanding".

CONCLUSION

By supporting treatment adherence, the PSOLife CARE Program may have empowered patients to better manage their psoriasis, increasing their satisfaction with treatment and quality of life.

Direct detection of free vitamin D as a tool to assess risk conditions associated with chronic plaque psoriasis

Introduction

Psoriasis is a major public health problem that results in high social and health costs. New approaches and methods are required to identify any conditions related to the disease and comorbidity development. The vitamin D deficiency is associated to psoriasis and could play an important role in its pathogenesis. However, the serum level of vitamin D is currently measured as total vitamin D, which is affected by wide variability. Therefore, the determination of the free form could be more significant, since it is independent of confounding factors. A cross-sectional study was performed to assess the association between chronic plaque psoriasis and serum level of free vitamin D, detected by a direct analytical method.

Methods

The levels of bioavailable vitamin D, total vitamin D and other metabolic parameters whose homeostasis is regulated by vitamin D were evaluated in 72 psoriasis patients and in 48 healthy controls. A direct immunoassay method was used to measure serum free vitamin D level. Analysis of covariance was performed to calculate estimated marginal means (EMM) and 95% confidence interval (CI), after adjustment for age, sex and BMI, within the two groups.

Results

Patients showed an EMM of 5.526 ± 0.271pg/ml, 95% CI 4.989-6.063; while controls an EMM of 6.776 ± 0.271 pg/ml, 95% CI 6.115-7.437.

Conclusions

Chronic plaque psoriasis patients exhibited a serum level of free vitamin D lower than controls. The direct immunoassay method could represent a useful tool to assess vitamin D status and identify a risk condition associated with the onset of the pathology.

Depressive symptoms and insecure attachment predict disability and quality of life in psoriasis independently from disease severity

Psoriasis is a multisystemic inflammatory disease with a significant burden in terms of disability and reduced quality of life. The interrelations between disease severity, psychological well-being, and disability and/or health-related quality of life (HRQOL) of psoriatic patients are not fully understood. The aim of the study was to assess the relative role of disease severity, depressive symptoms, and insecure attachment in predicting disability and HRQOL in 105 patients with psoriasis. Objective measures of disease severity included the Body Surface Area (BSA), the Psoriasis Area and Severity Index (PASI), and the Pain Visual Analog Scale (pain-VAS). The Sheehan Disability Scale (SDS). The Dermatology Life Quality Index (DLQI). Multivariate hierarchical regression analysis showed that a preoccupied style of attachment and the presence of depressive symptoms were predictors of disability and HRQOL over and above the contribution of demographic and clinical variables. The inclusion of attachment and depression into multivariate regression models improved substantially the prediction of disability and HRQOL. Conversely, the predictive utility of objective indicators of disease severity was scarce and only the pain-VAS emerged as a significant predictor of disability whereas there were no significant correlations between HRQOL and any of the objective indicators of disease severity. Measures capturing patients’ perspectives of the functional impact of disease should be routinely included in the clinical assessment of psoriasis.

The impact of COVID-19 pandemic in a cohort of Italian psoriatic patients treated with biological therapies

BACKGROUND

The beginning of 2020 has been marked by COVID-19 pandemic, with a strong impact on several national health systems worldwide.

OBJECTIVE

To describe the impact of COVID-19 pandemic in a cohort of Italian psoriatic patients treated with biologics.

METHODS

A telephone survey was conducted in May 4-10 2020 about the Italian lockdown period (March 9-May 3 2020) in a cohort of psoriatic patients treated with biologics, asking about any exposure to COVID-19, disease status, continuation of therapy, work activity and psychological status through Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS) and Brief Resilience Scale (BRS).

RESULTS

226 patients were interviewed, with no COVID-19 positive cases. Sixty-three of 226 (27.9%) described worsening of the disease with a correlation to drug withdrawal [43/226 (19%)]. Correlation was also found between the worsening of psoriasis and HADS anxiety, HADS depression, BRS and PSS abnormal scores considered both as categorical and continuous variables. No correlation was found between worsening of psoriasis and work activity.

CONCLUSION

Uncertainty about whether biologics could increase the risk of SARS-CoV-2 infection led to drug withdrawal with subsequent worsening of psoriasis. Moreover, psychological status also had a direct influence on the clinical course of the disease.

Treatment Pattern Analysis and Health-care Resource Consumption on Patients with Psoriatic Arthritis or Ankylosing Spondylitis Treated with Biological Drugs in a Northern Italian Region

Purpose

To analyze the treatment patterns of psoriatic arthritis (PSA) or ankylosing spondylitis (AS) patients under biological therapies and to evaluate in this population the health-care resource consumption and related costs.

Patients and Methods

A retrospective analysis was performed on administrative databases of the Veneto region. Patients ≥18 years with at least one prescription of biological drugs and a diagnosis at any level for PSA or AS from January 1, 2011 to December 31, 2016 (inclusion period) were included. Index date (ID) was defined as date of first biological drug prescription during inclusion period. Patients were characterized the year before ID and followed-up for one year after ID. The drug utilization profile in terms of adherence, persistence and therapeutic regimen changes, and the health-care resource consumption was analyzed during follow-up.

Results

A total of 2602 patients were included: 1857 with PSA and 745 with AS. In the PSA cohort, 40.3% of patients were prescribed adalimumab, 35.6% etanercept, 8.0% golimumab, 7.5% infliximab, 5.6% ustekinumab and 3.0% certolizumab. Percentage of PSA patients adherent to treatment was higher among ustekinumab patients (91.3%) and lower among etanercept users (54.3%). Persistence ranged from 53.2% (infliximab) to 70.3% (etanercept). Regarding AS cohort, 45.5% of patients were prescribed adalimumab, 26% etanercept, 17.3% infliximab, 9.7% golimumab and 1.5% certolizumab. Adherence ranged from 46.9% (etanercept) to 90.9% (certolizumab) and persistence from 62.8% (adalimumab) to 81.8% (certolizumab). Mean annual health-care costs (including costs for drug treatment, diagnostic services, specialist visits and hospital admissions) ranged from €9727 (certolizumab) to €14,994 (ustekinumab) among PSA patients and from €9875 (infliximab) to €12,991 (golimumab) among AS patients.

Conclusion

This study in Veneto region gave a picture of biological treatment patterns among PSA and AS patients in a real-world setting. Our findings showed the high degree of variability concerning utilization of each biological drug and provided insight on the economic burden of both diseases.

Pain and affective distress in arthritis: relationship to immunity and inflammation

INTRODUCTION

Most arthritides are associated with pain and psychological distress (clinically significant depression and anxiety). Pain and depression are mutually exacerbating; both may continue even when joint involvement appears well controlled. Area covered: There is strong evidence that arthritis-related stress impacts the central nervous system and, together with peripheral inflammatory changes, can cause central sensitization that can lead to chronic pain and worsening of affective distress. Cytokines and chemokines participate both in joint inflammation and in central sensitization. We review evidence of these relationships in five arthritides, namely rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, gout, and in osteoarthritis of the hips and knees. Central sensitization in these conditions results in long-lasting pain and psychological distress. Expert commentary: Chronic pain and depression are important but often neglected in the clinical assessment and treatment of arthritis. The potential role of biologic cytokines and Janus kinase inhibitors in dealing with these symptoms needs further study.