The treatment of psoriasis and psoriatic arthritis with etanercept: practical considerations on monotherapy, combination therapy, and safety

The Potential Benefits of Certolizumab Pegol in Patients with Concurrent Psoriatic Arthritis and Chronic Plaque Psoriasis: A Case Series and Review of the Literature

INTRODUCTION

We review the literature evaluating certolizumab in psoriasis and report our experience of treatment outcomes in a joint dermatology and rheumatology clinic.

METHODS

Patients with concomitant psoriatic arthritis (PsA) and psoriasis who had been commenced on certolizumab were included within our retrospective review. Data was collected for patient demographics, Patient Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI) and previous treatments. The literature was systematically searched using Pubmed and Scopus.

RESULTS

Very recent results from the CIMPASI-1 and CIMPASI-2 studies have demonstrated the high efficacy of certolizumab in the treatment of psoriasis at both week 16 and 48. Pooled results from these studies showed a PASI75 at week 16 and week 48 of 82% and 83.6% respectively, in the certolizumab 400 mg group. In our cohort of eight patients (two female; six male; median age 49 and mean PASI of 20.8) all had failed at least two systemic non-biologic agents. Objective improvements were observed in seven patients, with five achieving PASI90 and two demonstrating either PASI75 or PASI50.

CONCLUSION

Certolizumab is efficacious in both psoriasis and PsA, including in patients who are biologic failures, and could be considered as an alternative treatment modality.

Review of safety and efficacy of approved systemic psoriasis therapies

Psoriasis is a chronic inflammatory disease which affects nearly 3% of the adult US population. Due to the chronic nature of the disease and need for long-term treatment, psoriasis is associated with substantial disease burden and negative impact on patients' quality of life. In the past, systemic agents such as methotrexate, cyclosporine, and acitretin have been the mainstay treatment for moderate to severe psoriasis. Multiple new molecular targets have been recently identified, and novel biologic therapies directed at these targets have been approved leading to a paradigm shift in psoriasis management. However, despite the availability of several treatment options and continued introduction of highly efficacious biologics, undertreatment of psoriasis patients remains a huge problem. This can be largely attributed to several causes including high cost of biologics, lack of experience, and reluctance of practitioners to initiate or switch to systemic treatment regimens in moderate to severe psoriasis patients. In this article, we aim to provide a concise review of mechanism, safety, and efficacy of the approved systemic treatments for psoriasis.

Efficacy of the apitherapy in the treatment of recalcitrant localized plaque psoriasis and evaluation of tumor necrosis factor-alpha (TNF-α) serum level: A double-blind randomized clinical trial

BACKGROUND

No universal consensus about optimal modality for treating the recalcitrant localized plaque psoriasis (RLPP) is available.

OBJECTIVE

To evaluate the immunological and clinical therapeutic effect of using apitherapy in the treatment of RLPP.

METHODS

Randomized 50 patients with RLPP received apitherapy (n = 25) and placebo (n = 25) every week. Both treatments were injected into lesions at weekly intervals for a maximum of 12 treatments. Following up was 6 months later. Tumor necrosis factor-alpha (TNF-α) level was measured at pre-study and at 12th week.

RESULTS

A significant difference was found between the therapeutic responses of RLPP to the apitherapy and placebo groups (p<0.001). In the apitherapy group, complete response was achieved in 92% of patients. There was statistically significant decrease in TNF-α in the apitherapy group compared to the placebo group. No recurrence was observed in the apitherapy group.

CONCLUSION

Apitherapy is effective and a safe treatment for recalcitrant localized plaque psoriasis, when other topical or physical therapies have failed.

Drug therapies in dermatology

This article explores the current and emerging therapies for skin disease, with a particular focus on chronic plaque psoriasis and metastatic malignant melanoma. We discuss the current biological therapies used for psoriasis and those on the horizon, including small molecules and biosimilars. We also summarise the recent advances in the use of novel therapeutic agents in other dermatological diseases and outline the promise of translational research and stratified medicine approaches in dermatology. Better matching of patients with therapies is anticipated to have a major effect on both clinical practice and the development of new drugs and diagnostics.

Current and emerging systemic treatment strategies for psoriasis

Psoriasis is a common chronic inflammatory disease of the skin that has a significant impact on quality of life. A small number of systemic therapies are well established in psoriasis management. These have immunosuppressive and/or anti-proliferative effects on the skin and immune system. As understanding of the pathogenesis of psoriasis has advanced over the last 2 decades, there has been clearer appreciation of the genetic, cellular and immunological components of disease expression, which has provided new insight into potential therapeutic targets, including the development of biological therapies. Biologics offer a unique opportunity to block or inhibit specific key components of psoriasis pathogenesis. The introduction of tumour necrosis factor (TNF).α and interleukin (IL)-12/-23 inhibitors has resulted in remarkable clinical responses in patients with severe psoriasis and has led to the development of a range of other cytokine modulators currently undergoing investigation. More recently, research in keratinocyte biology and immune cell function, particularly intracellular signalling, has afforded additional opportunities to develop a range of small-molecule oral preparations that may prove effective in disease control. This paper reviews current and emerging systemic treatments in the management of psoriasis.

Innovative uses of tumor necrosis factor alpha inhibitors

Tumor necrosis factor alpha (TNF-alpha) is an inflammatory cytokine that is released by a variety of cell types, including immune effector cells and tissue-specific cells. TNF-alpha has been shown to promote inflammation via the activation and induction of cytokines interleukin 1 (IL-1), IL-6, and IL-8 and by the upregulation of adhesion molecules on endothelial cells leading to increased leukocyte extravasation. Theoretically, the blockade of TNF should have widespread potential in the treatment of numerous inflammatory diseases. Currently, 3 TNF-alpha inhibitors available in the United States are approved for psoriasis and psoriatic arthritis: infliximab, etanercept, and adalimumab. Numerous case reports and case series have been published in recent years reporting the off-label uses of these drugs in various inflammatory skin diseases. This review summarizes the most recent reports on 20 such conditions.

Update on the epidemiology and systemic treatment of psoriasis

Recent epidemiological observations reveal that the prevalence of psoriasis increases more rapidly in young women compared with young men, and that the prevalence of psoriasis may decrease in the elderly. Emerging evidence suggests that some potentially modifiable exposures, such as smoking, stress and obesity, may increase a patient's risk of developing psoriasis. The evolving literature suggests that psoriasis is associated with multiple other diseases, including cancer, cardiovascular disease, diabetes and psychiatric disease, and that psoriasis itself may be an independent risk factor for developing atherosclerosis and myocardial infarction. The treatment of moderate-to-severe psoriasis is undergoing a revolution with the advent of biological therapies that target the immunopathogenesis of psoriasis, such as tumor necrosis factor-alpha and T-cell function. The pharmacokinetics, pharmacodynamics, efficacy and safety profiles vary among biologicals and, therefore, drug and patient factors are important in selecting the optimum therapy. In this article, we focus on recent developments in the epidemiology and systemic treatment of psoriasis.

Update of the management of chronic psoriasis: new approaches and emerging treatment options

Psoriasis is a common, chronic inflammatory skin disease which is associated with a number of significant co-morbidities including: impairment of quality of life; cardiovascular disease; and a seronegative arthritis known as psoriatic arthritis. Our understanding of the pathogenesis of psoriasis has developed at a remarkable rate in recent years. These new insights have significantly changed our perception of the condition and have led to the development of several new treatment strategies. Biological agents have proved a major step forward in therapeutic options for psoriasis. The ability to clear, or almost clear, cutaneous disease has changed the outcomes and expectations of many patients with this disease. The impact on both physical and psychological health may be great. This review covers the clinical features and management of psoriasis with specific reference to new therapeutic options.

Infliximab and insulin resistance

Insulin resistance is the most important pathophysiologic feature of obesity, type 2 diabetes mellitus and prediabetic states. TNF-alpha, a proinflammatory cytokine, plays a pivotal role in the pathogenesis of inflammation-associated insulin resistance during the course of rheumatic diseases. Therapies aimed at neutralizing TNF-alpha, such as the monoclonal antibody infliximab, represent a novel approach for the treatment of rheumatic diseases and allow to obtain significant results in terms of control of the inflammatory process. In this article we reviewed the scientific evidence published in the literature about a potential role of TNF-alpha blockade in improving insulin resistance in non-diabetic rheumatic patients.

Emerging drugs for psoriasis

BACKGROUND

Psoriasis is a relatively common, chronic and disabling skin disease, due to a disturbed proliferation and differentiation of keratinocytes, accompanied by vascular alterations and infiltration of inflammatory cells with a local T(H)1-type cytokine immune response. There is no cure, but several treatment options are available.

OBJECTIVE

The treatment of psoriasis is far from being satisfactory, due to the impractical modalities of topical treatment and the suboptimal safety profile of the systemic treatments available. In the last few years, parallel to an improved understanding of the disease pathogenesis, there has been a boosting of research in new agents for the treatment of psoriasis. These new agents are the focus of this paper.

METHODS

After a short review of the treatment options already available (mainly based on the available systematic reviews), we focused on agents that are still in clinical development (Phase I - III) and have not yet entered the market. For the purpose of this study, we systematically searched the main registries of ongoing trials up to August 2008.

RESULTS/CONCLUSION

The field is very dynamic, with both immunopharmacology of recombinant DNA techniques and more traditional small-molecule pharmacology actively delivering new agents. With the increasing number of new options, there is a need for research systems that enable to effectively collect long-term safety data on treated patients.

Serum cytokines and bioumoral immunological characterization of psoriatic patients in long term etanercept treatment

The purpose of this study is to evaluate blood cytokines and immunological parameters in psoriatic patients during long-term treatment with Etanercept. Forty-five subjects of both sexes affected by psoriasis with or without arthritis entered the study and were treated with Etanercept according to international standard protocols. Biochemical blood analysis was carried out at baseline and during follow-up every second month. In particular, the following parameters were kept under control: antinuclear antibodies, anti-nDNA antibodies, anti-histone antibodies, blood cell count, circulating lymphocyte subtypes (CD3, CD4, CD8, CD16, CD19) and IgE. Cytokine profiles (IL-1-alpha, IL-1-beta, IL-6, IL-8, IL-10, IL-12, INF, TNF-alpha) were also evaluated in blood samples during the treatment up to 1 year of follow-up. A significant decrease in PASI score (p < 0.01) and in several cytokine levels was observed, particularly in IL-1, IL-6, IFN-gamma (p < 0.01) and to a lesser extent in TNF-alpha (p < 0.05). No statistically significant changes were recorded after 1 year of follow-up in blood immunological parameters, in particular in ANA titre, CD4/CD8 ratio, IgE levels, CD16, CD19 and eosinophils count. In conclusion, long-term treatment with Etanercept leads not only to a significant improvement in PASI score, but also to significant changes (reduction) in several proinflammatory and modulatory cytokines involved in the pathogenesis of the disease; on the other hand, there are no effects on immunological or bioumoral parameters showing that etanercept modulates rather than suppresses the physiological responses during psoriasis treatment.

Fungal infections complicating tumor necrosis factor alpha blockade therapy

Tumor necrosis factor a (TNF-alpha) blockade has emerged as a useful therapy for collagen vascular diseases or graft-vs-host disease. Fungal infections complicating such therapy have been reported sporadically. MEDLINE and PubMed databases (from January 1, 1966, to June 1, 2007) were searched for reports of invasive fungal infections (IFIs) associated with the 3 available anti-TNF- alpha agents, ie, infliximab, etanercept, and adalimumab. Of the 281 cases of IFI associated with TNF-alpha inhibition, 226 (80%) were associated with infliximab, 44 (16%) with etanercept, and 11 (4%) with adalimumab. Fungal infections associated with infliximab occurred a median of 55 days (interquartile range [IQR], 15-140 days) after initiation of therapy and 3 infusions of the medication (IQR, 2-5), whereas those associated with etanercept occurred a median of 144 days (IQR, 46-240 days) after initiation of therapy. The median age of patients was 58 years (IQR, 44-68 years), and 62% were male. Use of at least 1 other immunosuppressant medication, typically a systemic corticosteroid, was reported during the course of the fungal infection in 102 (98%) of the 104 patients for whom data were available. The most prevalent IFIs were histoplasmosis (n=84 [30%]), candidiasis (n=64 [23%]), and aspergillosis (n equals 64 [23%]). Pneumonia was the most common pattern of infection. Of the 90 (32%) of 281 cases for which outcome information was available, 29 fatalities (32%) were recorded. Tumor necrosis factor a blockade is associated with IFI across a range of host groups. A high index of suspicion in patients treated with TNF-alpha antagonists is recommended because the course of such infections can be serious or fulminant, and rapid access to health care should be provided. Surveillance of IFIs complicating TNF-alpha blockade and other biologic therapies is warranted through well-organized prospective patient registries.

Current and future management of psoriasis

Management of psoriasis begins with identification of the extent of cutaneous disease. However, a holistic, contractual approach to treatment is encouraged, with particular reference to psychosocial disability and quality-of-life issues. The presence of psoriasis on palms, soles, body folds, genitals, face, or nails, and concomitant joint disease, are also important when considering treatment options. An evidence-based approach is essential in delineating differences between the many available treatments. However, archaic approaches, especially combinational ones, are routinely used by some clinicians, with inadequate prospective or comparative evidence. Treatments currently available are: topical agents used predominantly for mild disease and for recalcitrant lesions in more severe disease; phototherapy for moderate disease; and systemic agents including photochemotherapy, oral agents, and newer injectable biological agents, which have revolutionised the management of severe psoriasis. Other innovative treatments are undergoing clinical studies, with the aim of maintaining safe, long-term control of the condition.

Off-label uses of biologics in dermatology: Rituximab, omalizumab, infliximab, etanercept, adalimumab, efalizumab, and alefacept (Part 2 of 2)

Recently, dermatologists have witnessed a revolution in our therapeutic armamentarium with the development of several novel biologic immunomodulators. Although psoriasis remains the only condition in dermatology for which the use of biologic immunomodulators has been approved by the Food and Drug Administration, these drugs have the potential to significantly impact the treatment of several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, and side-effect profile, as well as a review of the current literature on off-label uses of the CD20-positive B-cell antagonist rituximab, the IgE antagonist omalizumab, the tumor necrosis factor-alpha antagonists infliximab, etanercept, and adalimumab, and the T-cell response modifiers efalizumab and alefacept.

The incidence of arthropathy adverse events in efalizumab-treated patients is low and similar to placebo and does not increase with long-term treatment: pooled analysis of data from Phase III clinical trials of efalizumab

A large-scale, pooled analysis of safety data from five Phase III clinical trials (including open-label extensions of two of these studies) and two Phase III open-label clinical trials of efalizumab was conducted to explore whether arthropathy adverse events (AEs) were associated with efalizumab treatment in patients with moderate-to-severe chronic plaque psoriasis. Data from patients who received subcutaneous injections of efalizumab or placebo were stratified for analysis into phases according to the nature and duration of treatment. These included: the ‘first treatment’ phase (0–12-week data from patients who received either efalizumab, 1 mg/kg once weekly, or placebo in the five placebo-controlled studies); the ‘extended treatment’ phase (13–24-week data from seven trials for all efalizumab-treated patients); and the ‘long-term treatment’ phase (data from efalizumab-treated patients who received treatment for up to 36 months in two long-term trials). Descriptive statistics were performed and the incidence of arthropathy AEs per patient-year was calculated using 95% confidence intervals (CIs). During the first treatment phase, a similar proportion of patients had an arthropathy AE in the efalizumab group (3.3%; 58/1740 patients) compared with the placebo group (3.5%; 34/979 patients); the incidence of arthropathy AEs per patient-year was 0.15 in the efalizumab group (95% CI 0.11–0.19) and 0.16 in the placebo group (95% CI 0.11–0.22). Analysis of first treatment phase data from one study (n = 793) showed that the incidence of psoriatic arthropathy per patient-year was lower in efalizumab-treated patients (0.10; 95% CI 0.05–0.18) than in those given placebo (0.17; 95% CI 0.08–0.30). During the extended treatment phase, the incidence of arthropathy remained low (0.17; 95% CI 0.14–0.22). Data from two long-term studies showed that there was no increase in the incidence of arthropathy AEs over time in patients treated with efalizumab for up to 36 months. Patients who had an arthropathy AE during treatment with efalizumab appeared to be more likely to have a history of arthropathy prior to treatment. Efalizumab does not appear to increase the risk of arthropathy AEs compared with placebo.

Use of alefacept and etanercept in 3 patients whose psoriasis failed to respond to etanercept

This article reports on the combined use of alefacept and etanercept in 3 patients whose psoriasis failed to respond adequately to etanercept. All patients maintained improvement for at least 8 weeks after completing 12 weeks of alefacept. No adverse events or infections were reported, and CD4+ T-cell counts remained above normal limits.

Etanercept and demyelinating disease in a patient with psoriasis

The tumor necrosis factor-alpha antagonist (TNF-alpha) etanercept has been approved for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis. Earlier reports on the use of etanercept or infliximab in patients with rheumatoid arthritis, psoriatic arthritis, or juvenile rheumatoid arthritis suggested an increased risk of demyelinating disease. It is imperative that dermatologists have a keen awareness of this possible adverse event given the increased use of this class of drugs. We report a case of demyelinating disease occurring in a patient treated for psoriasis. The relation of TNF-alpha antagonist therapy to demyelinating disease/multiple sclerosis is explored. It is recommended that patients be diligently screened before starting TNF-alpha antagonist therapy and that vigilance for symptoms of demyelinating disease/multiple sclerosis be included in follow-up examinations during treatment with these drugs.

Psoriatic arthritis therapy advances

PURPOSE OF REVIEW

This paper will review the data published in 2004 on the treatment of psoriatic arthritis, which arthritis affects 6 to 39% of all patients with psoriasis.

RECENT FINDINGS

New data from placebo-controlled trials of anti-tumor necrosis factor agents, etanercept, infliximab, and adalimumab continue to show sustained effectiveness of these therapies in their ability to control the symptoms and signs of both arthritis and psoriasis, improve quality of life and function, and inhibit disease progression as measured by radiologic changes. Medications that inhibit T cells have been approved for the treatment of psoriasis and have been studied in psoriatic arthritis. The effectiveness of one of these agents, efalizumab, did not achieve statistical significance in the treatment of psoriatic arthritis. The results of a trial with a second agent, alefacept are pending public review.

SUMMARY

There has been a persistent increased focus on the diagnosis and treatment of psoriatic arthritis as newer and more effective drugs than traditional disease-modifying agents have become available.

Tratamiento de la psoriasis refractaria con etanercept

BACKGROUND AND OBJECTIVES

Etanercept is a dimeric fusion protein that binds to tumor necrosis factor and blocks inflammatory response. The purpose of this study was to assess the effects of etanercept and its maintenance in patients with severe and refractory psoriasis.

PATIENTS AND METHOD

Twenty two patients with severe and refractory psoriasis in an open-label clinical trial were studied. Patients received etanercept 50 mg/week subcutaneously during 6 months. PASI (Psoriasis Assessment and Severity Index) was used to monitor disease activity in each month of treatment and in the follow up. Results at weeks 12 and 24 are shown.

RESULTS

96% of patients improved their PASI basal score early at week 12. This improvement was maintained until week 24. Etanercept was well tolerated without any significant adverse reaction. Time until relapse was 2.27 +/- 0.59 months (CI 95%: 1.94-2.60).

CONCLUSION

Etanercept seems an effective therapy for severe and refractory psoriasis yet long-term dosing and safety studies of etanercept in psoriasic patients are needed.