Combining the new biologic agents with our current psoriasis armamentarium

Efficacy and Safety of a Second Adalimumab Treatment Cycle in Psoriasis Patients who Relapsed after Adalimumab Discontinuation or Dosage Reduction: A Double-Blind, Randomized, Placebo-Controlled Trial

Objective

To evaluate re-treatment with weekly adalimumab in patients with moderate to severe psoriasis who had been successfully treated with weekly adalimumab but relapsed following randomization to either dosage reduction or discontinuation.

Methods

Patients who had achieved a Psoriasis Area and Severity Index (PASI) response of 50 or greater after 12 weeks on adalimumab 40 mg weekly in a previous study (M02-538), but then fell below a PASI 50 response within 12 weeks following reduction of dosage frequency to adalimumab 40 mg every other week or treatment discontinuation, could enter study M03-596 and receive open-label re-treatment with 12 weeks of weekly adalimumab.

Results

Thirty-two patients relapsed on or before week 24 of M02-538 and entered study M03-596. Overall, 81.3% (26 of 32) again achieved a PASI 50 response after 12 weeks of re-treatment. Of the 19 M03-596 patients who had a PASI 75 response at week 12 of M02-538, 12 (63.1%) again achieved a PASI 75 response at week 12 of M03-596.

Conclusion

Most patients who had initially responded to weekly adalimumab and who relapsed after randomization to a lower dosage or discontinuation regained response upon re-treatment with weekly adalimumab.

Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel

Background:

Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5

Objective:

A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis.

Methods:

The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8–14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion.

Results:

The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm.

Conclusion:

The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.

Biologic Therapeutics in the Treatment of Psoriasis. Part 1: Review

Background:

Psoriasis is a chronic inflammatory skin disease principally mediated by activated T cells, which release proinflammatory cytokines with reactive epidermal changes in the skin, producing the characteristic lesions of psoriasis. New research into possible treatment options has been inspired by increased understanding of the pathophysiology of psoriasis and advances in immunology and molecular biology permitting the development of targeted, highly active biologic agents.

Objective:

The aim of this article is to review the efficacy and safety of five biologic therapeutics in the treatment of moderate to severe psoriasis and to provide practical guidelines for integration of these agents in the management of psoriasis.

Methods:

We searched MEDLINE (1966–2005) for articles containing the key words: alefacept, efalizumab, etanercept, infliximab, and adalimumab and searched recent conference abstracts.

Results:

Emerging immunotherapeutic agents (fusion proteins, recombinant cytokines, fusion toxins, or antibodies) target T cells or cytokines responsible for plaque formation that is characteristic of psoriasis. Alefacept is the first biologic to be approved in both the United States and Canada. More recently, efalizumab and etanercept and infliximab have been approved in the United States and Canada for plaque-type psoriasis. Adalimumab is currently in phase III clinical trials.

Conclusion:

These novel biologics offer an intriguing and effective treatment option for patients with moderate to severe psoriasis.

Use of Alefacept for Preconditioning in Multiply Transfused Pediatric Patients with Nonmalignant Diseases

Transfusion-related alloimmunization is a potent barrier to the engraftment of allogeneic hematopoietic stem cells in patients with nonmalignant diseases (NMDs). Memory T cells, which drive alloimmunization, are relatively resistant to commonly used conditioning agents. Alefacept, a recombinant leukocyte function antigen-3/IgG1 fusion protein, targets CD2 and selectively depletes memory versus naive T cells. Three multiply transfused pediatric patients with NMD received a short course of high-dose i.v. alefacept (.25 mg/kg/dose on days -40 and -9 and .5 mg/kg/dose on days -33, -26, -19, and -12) before undergoing unrelated allogeneic transplant in the setting of reduced-intensity pretransplant conditioning and calcineurin inhibitor-based post-transplant graft-versus-host disease (GVHD) prophylaxis. Alefacept infusions were well tolerated in all patients. Peripheral blood flow cytometry was performed at baseline and during and after alefacept treatment. As expected, after the 5 weekly alefacept doses, each patient demonstrated selective loss of CD2(hi)/CCR7(-)/CD45RA(-) effector memory (Tem) and CD2(hi)/CCR7(+)/CD45RA(-) central memory (Tcm) CD4(+) and CD8(+) T cells with relative preservation of the CD2(lo) Tem and Tcm subpopulations. In addition, depletion of CD2(+) natural killer (NK) cells also occurred. Neutrophil recovery was rapid, and all 3 patients had 100% sorted (CD3/CD33) peripheral blood donor chimerism by day +100. Immune reconstitution (by absolute neutrophil, monocyte, and lymphocyte counts) was comparable with a cohort of historical control patients. All 3 patients developed GVHD but are all now off immune suppression and >2 years post-transplant with stable full-donor engraftment. These results suggest that alefacept at higher dosing can deplete both memory T cells and NK cells and that incorporating CD2-targeted depletion into a reduced-intensity transplant regimen is feasible and safe in heavily transfused patients.

Use of biologic agents in combination with other therapies for the treatment of psoriasis

Psoriasis is a chronic inflammatory skin disorder, which is associated with a significant negative impact on a patient’s quality of life. Traditional therapies for psoriasis are often not able to meet desired treatment goals, and high-dose and/or long-term use is associated with toxicities that can result in end-organ damage. An improved understanding of the involvement of cytokines in the etiology of psoriasis has led to the development of biologic agents targeting tumor necrosis factor (TNF)-α and interleukins (ILs)-12/23. While biologic agents have improved treatment outcomes, they are not effective in all individuals with psoriasis. The combination of biologic agents with traditional therapies may provide improved therapeutic options for patients who inadequately respond to a single drug or when efficacy may be increased with supplementation of another treatment. In addition, combination therapy may reduce safety concerns and cumulative toxicity, as lower doses of individual agents may be efficacious when used together. This article reviews the current evidence available on the efficacy and safety of combining biologic agents with systemic therapies (methotrexate, cyclosporine, or retinoids) or with phototherapy, and the combination of biologic agents themselves. Guidance is provided to help physicians identify situations and the characteristics of patients who would benefit from combination therapy with a biologic agent. Finally, the potential clinical impact of biologic therapies in development (e.g., those targeting IL-17A, IL-17RA, or IL-23 alone) is analyzed.

Biologic therapy with or without topical treatment in psoriasis: what does the current evidence say?

Biologic therapy represents a relatively new class of drugs which have revolutionized the treatment of psoriasis and are used with increasing frequency in order to control this chronic, systemic inflammatory disease. However, it is unclear what role there is for combination therapy of biologics with traditional topical agents. The purpose of this article is to assess the literature on the role of topical agents as adjuvants to biological treatments in the treatment of psoriasis and identify areas for further research. A MEDLINE search was performed in order to identify English-language publications from 1996 to 2014 examining combination biologic therapy with topical medications in the treatment of psoriasis. Data from these clinical studies are summarized and the outcomes are discussed. In general, the addition of adjuvant topical therapy to systemic biologic therapy allowed for a reduction in dosage and side effects of both agents, maintenance of initial response to biologics, treatment of recalcitrant lesions in partial responders, and potential acceleration of response to biologic therapies. The current data, though limited, suggest that using topical therapies as adjunct treatment to biologics is a well tolerated and effective means of controlling psoriasis and improving quality of life for patients. However, the treating physician should remain attentive to signs of adverse events and seek opportunities to reduce the dose or treatment frequency during chronic use.

Phototherapy, psoriasis, and the age of biologics

Over 10 years have passed since the first approval of a biologic agent for the treatment of psoriasis. No one can argue that the arrival of this entirely new, highly effective class of medications has not forever changed the therapeutic landscape for psoriasis. Traditional treatments such as phototherapy, however, remain both viable and effective therapies, both as standalone treatments and in combination with biologics. In general, synergistic effects are noted for combinations utilizing phototherapy; however, the long-term impact of these combinations on skin cancer development has yet to be fully determined. Increasing financial pressures for cost-effective therapies augment the appeal of phototherapy and other traditional treatments as compared with the more costly biologics. Phototherapy also remains strong outside the realm of psoriasis, in the management of atopic dermatitis, vitiligo, and cutaneous T-cell lymphoma, among other conditions. Phototherapy will remain a cornerstone in the management of psoriasis as well as nonpsoriatic skin conditions, as its efficacy is well known, its financial cost is reasonable, it is readily compatible with other therapeutics, and its utility is historically proven.

Advances in the treatment of moderate-to-severe plaque psoriasis

PURPOSE

Advances in the treatment of moderate-to-severe plaque psoriasis, including new biological agents and related drugs, are reviewed.

SUMMARY

Most patients with psoriasis have mild disease that can be treated with topical agents alone; however, over one third of patients have more-extensive disease, called moderate-to-severe plaque psoriasis. Although effective, traditional therapies, including methotrexate, cyclosporine, acitretin, and phototherapy, have serious adverse effects that limit both the initiation and duration of treatment, necessitating sequential treatment regimens. With the increasing knowledge of the immune nature of the disease, biological agents that target T lymphocytes, tumor necrosis factor (TNF)-α, interleukin (IL)-12, and IL-23 have been used successfully in moderate-to-severe psoriasis. Etanercept, adalimumab, and infliximab are also highly effective in the treatment of moderate-to-severe plaque psoriasis. Ustekinumab, a new agent that targets IL-12 and IL-23, was approved for marketing in 2009 and offers similar efficacy and safety profiles to the anti-TNF agents. While the rapid onset and apparent lack of long-term toxicity of biological agents make them major advances in the treatment of more severe forms of psoriasis, the lack of extensive experience with these agents in patients with psoriasis leaves several unresolved issues that must be addressed before their exact place in therapy can be determined.

CONCLUSION

With the development of biological therapies over the past 10 years, health care providers have a much broader choice of highly effective agents with which to treat patients suffering from moderate-to-severe plaque psoriasis. Though costly to use, biological agents offer considerable advantages over previously available systemic therapies.

A clinical trial of combination therapy with etanercept and low dose cyclosporine for the treatment of refractory psoriasis

BACKGROUND

Over the past decade, combination therapies have become a mainstay of dermatologic care in psoriasis. Combination therapies are often more effective and safer than large dose single-agent therapies. With the emergence of new biologic therapies, dermatologists now have a wider array of tools to treat psoriasis. Although much data exists regarding cyclosporine or biologic agents alone for psoriasis, little is known about the efficacy, safety and tolerability of combination regimens.

OBJECTIVE

We designed a study to evaluate the efficacy and safety of etanercept and cyclosporin combination therapy in patients with refractory psoriasis.

METHODS

We administered oral cyclosporine (200 mg daily) and subcutaneous etanercept 50 mg weekly injections until symptoms improved, then maintained treatment at a reduced dose. Seven patients with refractory psoriasis were evaluated 4 weekly.

RESULTS

All 7 patients showed rapid responses to combination therapy. Mean Psoriasis Area and Severity Index reductions following conditioning therapy (mean: 6.85 weeks) and maintenance therapy (mean: 56.5 weeks) were 94.9% and 93.2%, respectively.

CONCLUSION

Etanercept and low-dose cyclosporine combination therapy appears to be a safe and efficacious alternative treatment strategy for patients with refractory psoriasis. The combination induced rapid improvement in patients with refractory psoriasis and dramatically improved their quality of life. Clinical studies including larger patient cohort are required to validate the safety and efficacy of this combination therapy.

Cyclosporine and psoriasis: 2008 National Psoriasis Foundation Consensus Conference

BACKGROUND

Cyclosporine is a valuable option for the treatment of psoriasis. This report summarizes studies regarding the use of cyclosporine since the last guidelines were published in 1998.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to achieve a consensus on new updated guidelines for the use of cyclosporine in the treatment of psoriasis.

METHODS

Reports in the literature were reviewed regarding cyclosporine therapy.

LIMITATIONS

There are few evidence-based studies on the treatment of psoriasis with cyclosporine.

RESULTS

A consensus was achieved on the use of cyclosporine in psoriasis including specific recommendations on dosing, monitoring, and use of cyclosporine in special situations. The consensus received approval from members of the National Psoriasis Foundation Medical Board.

CONCLUSIONS

Cyclosporine is a safe and effective drug for the treatment of psoriasis. It has a particularly useful role in managing psoriatic crises, treating psoriasis unresponsive to other modalities, bridging to other therapies, and treating psoriasis within a rotational scheme of other medications. Appropriate patient selection and monitoring will significantly decrease the risks of side effects.

Retrospective assessment of PASI 50 and PASI 75 attainment with a calcipotriol/betamethasone dipropionate ointment

BACKGROUND

The US National Psoriasis Foundation recently recommended that PASI 50 and PASI 75 response rates be used in clinical trials to enable comparisons across studies of different psoriasis therapies. To date, these response rates have not been reported for the two-compound ointment containing calcipotriol and betamethasone dipropionate (Daivobet/Dovobet; LEO Pharma, Ballerup, Denmark). Further, in order to compare Daivobet with other therapeutics recently presented to the European regulatory authorities and the FDA, comparison with the biologicals, efalizumab, etanercept and alefacept, were also made.

OBJECTIVES

To present the PASI 50 and PASI 75 results for the two-compound ointment containing calcipotriol and betamethasone dipropionate.

METHODS

Data from six phase III studies conducted with the two-compound ointment were pooled and the PASI 50 and PASI 75 response rates calculated for patients with severe (PASI>or=17) or less severe disease (PASI<17) at treatment commencement. Results for the biological therapies, efalizumab, etanercept and alefacept, were obtained from relevant published phase III studies.

RESULTS

PASI 50 and PASI 75 were achieved by more patients treated with the two-compound ointment than with the individual components. In patients with severe disease, the PASI 50 response rate after 4 weeks' treatment was 88.8% with the two-compound ointment, 69.2% with betamethasone dipropionate, 53.8% with calcipotriol, and 30.0% with ointment vehicle. In comparison, 12 weeks' treatment with the biologicals resulted in PASI 50 response rates of 59% with efalizumab, 74% with etanercept, and 56% with alefacept.

CONCLUSIONS

The two-compound ointment is effective, producing a PASI 50 and PASI 75 response in greater than 80% and 50% of patients, respectively, regardless of psoriasis severity.

Phase II randomized, placebo-controlled trial of M. vaccae-derived protein (PVAC) for the treatment of psoriasis

The treatment effect against psoriasis of an antigen (delipidated, deglycolipidated form of M. vaccae-PVAC) was investigated. One hundred and sixty-five patients were enrolled in three arms (50 or 15 microg or placebo), each receiving a total of two intradermal injections (days 0 and 21). At week 12, a 75% decrease in psoriasis area and severity index was similar among the studied groups (13, 9 and 18%, p=0.429). The overall incidence of adverse events was significantly higher in the PVAC treated groups when compared to placebo (98.2, 87.3 and 70.9%; p<0.001) largely due to local reactions that were limited for the most part to grades 1 and 2 in severity and were self-limiting. Despite its overall safety, PVAC was not clearly indicated to be superior to placebo in the treatment of psoriasis in this study.

A clinician's paradigm in the treatment of psoriasis

Psoriasis is a chronically recurring inflammatory disease that affects the skin, scalp, and joints. It ranges in severity from mild to severe, and patients with moderate to severe disease experience significant deterioration in quality of life. The goals of psoriasis treatment are to gain initial and rapid control of the disease process, decrease the percentage of body surface area involved, decrease plaque lesions, achieve and maintain long-term remission, minimize adverse events, and improve patient quality of life. Therapy varies depending on disease severity and spread and will shift from control of acute flares to long-term maintenance. Topical treatment for mild psoriasis includes the use of topical corticosteroids, calcipotriene, tazarotene, topical tars, anthralin, and keratolytics. Treatment of moderate to severe psoriasis includes systemic therapies, such as methotrexate, acitretin, cyclosporine, and biologic agents. Treatment can be effected using combination, rotational, or sequential regimens. Treatment algorithms developed by a 2002 consensus conference are described. Because some degree of therapy will always be necessary, ranging from maintenance of long-term remission to control of acute psoriasis flares, each patient requires an individualized plan.

Infliximab in the treatment of moderate to severe atopic dermatitis

BACKGROUND

Chronic use of standard therapies for atopic dermatitis (AD) is associated with variable efficacy and potential side effects. Targeted therapeutic approaches, such as the inhibition of tumor necrosis factor-alpha, may be a novel option.

OBJECTIVE

This investigator-initiated, open, prospective, single-center, pilot study was conducted to evaluate the long-term efficacy and safety of infliximab in patients with AD.

METHODS

Nine patients with moderate or severe AD were enrolled. AD in these patients was resistant to conventional therapy. Infliximab 5 mg/kg was administered by intravenous infusion at weeks 0, 2, 6, 14, 22, 30, and 38, and patients were followed for 46 weeks.

RESULTS

Induction therapy with infliximab significantly improved all clinical parameters, but this improvement was not sustained through maintenance therapy. Only two patients with severe AD achieved an excellent clinical response by 46 weeks.

CONCLUSIONS

Infliximab monotherapy may be an additional therapeutic option for the management of refractory severe AD.

Psoriasis: a fresh look

Psoriasis is a disease characterized by scaly skin lesions secondary to keratinocyte hyperplasia. The presence of active T cells in the lesions, experimental observations on disease transfer, and therapeutic efficacy of specific immunosuppressive drugs have led to the identification of the activated T lymphocyte as the primary factor for keratinocyte stimulation. Understanding the pathways of pathogenesis is fundamental in evolving therapies for intervention at different points in the pathogenic model and for curtailing the process. Advances in biotechnological methods have helped to create designer molecules and proteins that specifically recognize target receptors and chemicals that modify their actions. These drugs, termed "biologic response modifiers," are now being studied as specific immunosuppressive agents producing different T-cell and cytokine effects in psoriasis.

Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel

BACKGROUND

Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5

OBJECTIVE

A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis.

METHODS

The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8-14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion.

RESULTS

The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm.

CONCLUSION

The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.

Combining traditional agents and biologics for the treatment of psoriasis

Psoriasis patients deserve long-term control of their disease with optimal safety. Traditional agents (methotrexate, cyclosporine, retinoids, and photochemotherapy [PUVS]), although providing excellent short-term control, may produce acute or chronic toxicities, thus limiting their usage. Dermatologists are well versed in combination and rotational therapies for psoriasis, using these and other agents. With the advent of biologic therapies (three currently approved, and others pending), the potential for safer long-term psoriasis control is being realized. A review of the literature, plus our personal experience in using combinations of traditional agents and biologics, is presented.

Identifying and controlling metabolic skin disorders: eczema, psoriasis, and exercise-induced urticaria

Inflammatory skin conditions can present obstacles that affect athletic participation. In eczema and psoriasis, cutaneous lesions can lead to skin breakdown, which may disqualify an athlete from participation and may also contribute to secondary infection. Adequate control of chronic skin conditions can, therefore, ensure more consistent athletic participation, and successful treatment may improve social functioning, as well. Clinicians treating athletes who have exercise-induced urticaria should be aware of the need for close observation and continual reassessment to distinguish between cholinergic urticaria and exercise-induced anaphylaxis.

Tratamento sistêmico da psoríase - Parte II: Imunomoduladores biológicos

Em continuidade ao capítulo da edição anterior dos Anais Brasileiros de Dermatologia, nesta segunda parte da EMC-D serão discutidas as novas drogas, os imunomoduladores biológicos, que agem em determinadas fases da imunopatogênese da doença, modificando fenotipicamente sua evolução. Também serão discutidos alguns aspectos imunológicos que, atualmente, são responsáveis pelo desencadeamento da doença