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

Selecting the Best Combined Biological Therapy for Refractory Inflammatory Bowel Disease Patients

Current medical treatment for inflammatory bowel disease (IBD) does not achieve 100% response rates, and a subset of refractory and severely ill patients have persistent active disease after being treated with all possible drug alternatives. The combination of two biological therapies (CoT) seems a reasonable alternative, and has been increasingly tested in very difficult cases. The present review suggests that CoT seems to be safe and effective for refractory and severely ill IBD patients. Ustekinumab plus vedolizumab and vedolizumab plus anti-TNF were the most used CoTs for Crohn's disease. For ulcerative colitis, the most used CoTs were vedolizumab plus anti-TNF and vedolizumab plus tofacitinib. The aforesaid CoTs have shown good efficacy and few adverse events have been reported.

Combining Biologics in Inflammatory Bowel Disease and Other Immune Mediated Inflammatory Disorders

Current therapies used in the treatment of inflammatory bowel disease (IBD) are not effective in all patients. Biologic agents result in approximately 40% remission rates at 1 year in selected populations, prompting a growing interest in combining biologic therapy to improve outcomes. There are limited published data regarding the efficacy and safety of combination targeted therapy in IBD specifically, which include only 1 exploratory randomized control trial and 3 case reports or series. This review evaluates the published literature regarding this therapeutic paradigm in IBD and its extensive utilization in the treatment of other immune-mediated inflammatory disorders. The combination of biologic therapies demonstrates variable degrees of efficacy and highlights some safety concerns, depending upon the agents used and the disease state treated. A trial (Clinical Trials.gov Identifier: NCT02764762) combining vedolizumab and adalimumab is currently underway evaluating the effectiveness and safety of this approach in patients with Crohn's disease, which should provide further insight into this treatment concept. While combination biologic therapy is an attractive strategy, the lack of consistent superior efficacy as well as safety concerns militates the need for further trials prior to its general application in IBD.

Cost-effectiveness and impact on quality of life of alefacept in the treatment of psoriasis

Although alefacept was the first biologic agent approved to treat psoriasis, it is used less frequently than other biologic therapies. Alefacept decreases the Psoriasis Area and Severity Index (PASI) score and enhances the quality of life of patients with psoriasis. Unlike other biologics, alefacept can also induce remission of psoriasis. If reports in Pubmed and the package insert are considered to be surrogates for side effects, alefacept appears to be safer than other biologics. Alefacept can be effective against psoriatic arthritis, especially in combination with methotrexate. The response of psoriatics to alefacept, however, is inconsistent and often incomplete. Alefacept also has the highest cost of any biologic agent as measured by patients achieving PASI-75 and cost per patient achieving Dermatology Life Quality Index Minimal Important Difference. Traditional systemic therapies such as spriatane, ciclosporine, as well as phototherapy and TNF-alpha, possess firmer and superior pharmacoeconomic foundations, although some of these apparent cost-benefit disadvantages may take into account the ability of alefacept to induce remission after cessation of treatment.

Alefacept: its safety profile, off-label uses, and potential as part of combination therapies for psoriasis

OBJECTIVES

To review literature regarding alefacept, a biologic therapy for psoriasis.

METHODS

A PubMed search using the term alefacept was done through December of 2006 and articles reviewed. Abstracts concerning alefacept presented at the meeting of the Annual meeting of the American Academy of Dermatology in 2004, 2005 and 2006 were reviewed. Attention was paid to alefacept's safety profile, off-label uses, and potential as part of combination therapy for psoriasis.

RESULTS

Alefacept is a very safe treatment for psoriasis alone or in conjunction with other therapies. It has been used, anecdotally, with some effect in diseases besides psoriasis.

CONCLUSIONS

The utility of checking CD4 counts while administering alefacept for 12 weeks is unclear. While no side effects have been linked to CD4 counts lower than 250/cc(3), due to the fact that in clinical trials alefacept was discontinued when the CD4 count was lower than 250/cc(3), the effect of administration of alefacept to patients with low CD4 counts is unknown. Alefacept appears to be the safest biologic therapy for the treatment of psoriasis, safety that has been borne out in patients who have received as many as nine courses of alefacept. Intramuscular alefacept's consistent ability to decrease the psoriasis area and severity index (PASI) scores in psoriatic patients is not as great as phototherapy, cyclosporine, methotrexate or tumor necrosis factor alpha blockers. Repeated courses of alefacept are best used in patients who have previously responded to the medication, so that patients who have found alefacept useful when grouped achieve higher and more consistent improvements of PASI scores with each successive course of alefacept. A test that would identify likely responders would greatly increase the utility of the medication. While reports assessing the combination of alefacept and narrow band ultraviolet B phototherapy have only studied small numbers of patients ( approximately 60), the combination of phototherapy and alefacept appears synergistic and extremely effective with studied patients achieving PASI 75 in more than 75% of cases and thus merits further study. Combinations of alefacept with etanercept, acitretin, and methotrexate have been used anecdotally but effectively to treat recalcitrant psoriasis. Reported effective off-label uses of alefacept include: generalized lichen planus, alopecia areata, steroid-resistant or steroid-dependent acute graft-versus-host disease, scleroderma, nail psoriasis, and palmoplantar psoriasis.