Alefacept for the treatment of psoriasis: A review of the current literature and practical suggestions for everyday clinical use

Initiating and Monitoring Patients on Biologic Therapy for Psoriasis beyond the FDA: Our more Cautious Approach

Biologics are offering new hope for patients with moderate to severe chronic plaque psoriasis and psoriatic arthritis, and every day more dermatologists are prescribing these medications for their patients. Prior to prescribing a biologic it is important to conduct the proper screening to determine if your patient is an appropriate candidate. While patients are being treated with biologics they need to be monitored carefully to maximize the benefit of the agent and minimize harmful side effects. Apart from the recommendations and requirements of the U.S. Food and Drug Administration (FDA), there are as yet no consensus statements or guidelines addressing the appropriate approach to initiating and monitoring patients being treated with biologics. In this article we will discuss our own approach to initiating and monitoring that we believe is appropriate for patients being treated with biologics. Our recommendations, which in many ways go beyond the recommendations and requirements of the FDA, should not be interpreted as the standard of care.

Infliximab (Remicade) in the treatment of psoriatic arthritis

Elucidation of the cellular immunopathology and cytokine profile of psoriatic arthritis (PsA), a chronic inflammatory disease associated with psoriasis, has resulted in the development of a number of novel biologic therapies. Among these biologics, tumor necrosis factor-alpha (TNF-alpha) inhibitors have been used successfully to treat patients suffering from rheumatoid arthritis or psoriasis. The pivotal role of TNF-alpha in the pathogenesis and progression of PsA suggested that anti-TNF-alpha agents could be effective in controlling PsA. The results from two large, randomized, double-blind, placebo-controlled trials in patients with moderate to severe PsA indicated that the anti-TNF-inhibitor, infliximab, can control both the joint and skin manifestations of the disease. This review focuses on the clinical development of infliximab as a treatment for PsA. The development of other anti-TNF-alpha biologics is also discussed.

The AWARE study: methodology and baseline characteristics

BACKGROUND

Alefacept was the first biologic therapy approved by Health Canada for the treatment of moderate to severe chronic plaque psoriasis and is used either alone or as part of combination therapy.

OBJECTIVE

AWARE (Amevive Wisdom Acquired from Real-World Evidence) is a multicenter, observational phase IV Canadian study of psoriasis patients treated with alefacept. This study's main goals were to develop a shared, real-time, national clinical database to support best practice and optimize the care of patients receiving alefacept and to gain an understanding of how alefacept is used in Canadian clinical practice. Baseline patient demographic data are described herein.

METHODS

Patients with chronic plaque psoriasis were enrolled from 37 clinics across Canada. Subjects received at least one course of alefacept treatment followed by a period of at least 12 weeks off treatment and were prospectively followed for at least 60 weeks. Baseline assessments included patient demographics, relevant medical history, psoriasis and treatment history, reasons for initiating alefacept, enrolling physician's initial alefacept treatment plan and strategy, percent body surface area (BSA) involvement with psoriasis, and physician's baseline assessment of disease control. Subsequent assessments at each follow-up visit included the patient's response and the physician's assessment.

RESULTS

A total of 426 adult patients with predominantly chronic plaque psoriasis, with or without other types of psoriasis, were enrolled into the AWARE registry. Patients generally had moderate to severe psoriasis, with more than half (55.8%) having little or no disease control at baseline as assessed by their clinician, and 77% had > 10% BSA involvement with psoriasis. All patients in the AWARE patient population were receiving one or more treatments for psoriasis prior to or at the time of enrolment, and the majority continued to receive concomitant treatments at the time of study enrolment.

CONCLUSION

The AWARE registry enrolled a broad group of real-world patients with chronic plaque psoriasis treated with alefacept in clinical practices across Canada.

The added therapeutic efficacy and safety of alefacept in combination with other (systemic) anti-psoriatics in refractory psoriasis

OBJECTIVE

Alefacept is a biologic treatment for psoriasis, with a selective effect on memory effector T cells. Few data are available on the combination of alefacept with either topical or systemic anti-psoriatics. We studied the effect of alefacept combination treatment on clinical disease severity scores and on circulating T-cell subsets.

METHODS

Twelve patients with moderate-to-severe psoriasis were included and treated with alefacept for a period of 12 weeks. Patients were allowed to continue the anti-psoriatic therapies they used prior to the study. Severity of disease and expression of T-cell markers CD4, CD8, CD45RA, CD45RO, CD94, CD161, CD25, and CLA were assessed at baseline and after treatment.

RESULTS

Seven of 12 included patients used a concomitant systemic therapy: either methotrexate (n = 4), acitretin (n = 2) or cyclosporine (n = 1). PASI reductions in this group after 12 and 24 weeks were 40% and 55%, respectively. Several lymphocyte subsets showed a reduction in circulating numbers. These decreases were independent of the use of an additional systemic psoriasis therapy.

CONCLUSIONS

The concomitant use of systemic anti-psoriatic medication in combination with alefacept has a noteworthy impact on efficacy results. No differences in circulating psoriasis-relevant T-cell populations between patients with or without an additional systemic treatment were seen.

Adhesion molecules in cutaneous immunity

Skin serves a vital role, providing protection from the broad array of pathogens present in our environment. In addition to the passive barrier functions of the skin, mammals have evolved a robust and versatile surveillance and rapid response system for recognition and elimination of invading organisms. This immune surveillance network directs the movement of immune cells, regulating homeostatic populations of immune cells in the skin, as well as recruitment to sites of inflammation. In this review, we discuss current understanding of the regulation and function of adhesion molecules in cutaneous immune surveillance and their relevance to the immunopathology of inflammatory skin disease.

Cutaneous sarcoidosis successfully treated with alefacept

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology that affects multiple organ systems, including the pulmonary, lymphatic, skeletal, and integumentary systems. Improved understanding of the intrinsic immunology and molecular biology in sarcoidosis can be applied to the treatment of this disease. Alefacept is a human fusion protein consisting of the extracellular domain of leukocyte function-associated antigen 3 fused with the Fc portion of human immunoglobulin G1. It works by blocking the interaction between antigen-presenting cells and T cells to inhibit activation and by inducing apoptosis of CD4+ T cells. In this case report, we describe a 46-year-old patient with recalcitrant lupus pernio who was successfully treated with alefacept.

OBJECTIVE

To determine whether T-cell inhibition, specifically the use of alefacept, may be used to treat a patient with recalcitrant cutaneous sarcoidosis.

METHODS

Case report.

RESULTS

There was a modest clinical improvement after 8 weeks of intramuscular injections of alefacept.

CONCLUSION

This case report provides further evidence of successful treatment of sarcoidosis with biologic agents directed against T-lymphocyte activation.

The evaluation of psoriasis therapy with biologics leads to a revision of the current view of the pathogenesis of this disorder

Psoriasis is a common chronic, recurring skin disease that is characterised by typical macroscopic and microscopic skin alterations. It is widely accepted that the immune system plays an important role in the pathogenesis of this disorder. Since the early 1990s, the dominant role of a subpopulation of T cells, so-called T1 cells, and their prominent cytokine IFN-gamma has been assumed in the pathogenesis of psoriasis. Surprisingly, the comparison of the therapeutic success of treatments with recombinant proteins directed against defined immunological structures shows that those that directly affect T cells (alefacept, efalizumab, Hu-max-CD4, OKTcdr4a) were clearly less effective than those targeting TNF-alpha (etanercept, adalimumab, infliximab). For this reason, the authors critically re-evaluated the view of psoriasis pathogenesis and postulate that in the majority of patients the T1 cells do not play a dominant role in the clinical, visible stage of this disease.

Immunobiologics in the treatment of psoriasis

The pathogenesis of various inflammatory cutaneous diseases such as psoriasis, atopic dermatitis and mycosis fungoides relies greatly on the abnormal function of T cells. Fundamental knowledge of the role of T cells in the cutaneous immune response has led to the development and production of biologic molecules designed to block T cell function at various steps, specifically activation (i.e. alefacept, efalizumab), trafficking into inflamed skin (i.e. efalizumab) and effector function under cytokine control (i.e. etanercept, infliximab, adalimumab, and anti-IL-12 antibody). We review the immune abnormalities and the role of T cells in psoriasis, and the recent biologic therapies, which share the common mission to hinder T cell activity in inflammatory diseases. An advantage from the preciseness of these biologic therapies is the potential limit of non-specific and potentially devastating organ toxicity, which commonly plagues other systemic therapies.