Repeat courses of intravenous alefacept in patients with chronic plaque psoriasis provide consistent safety and efficacy

In vitro Evidence That Combination Therapy With CD16-Bearing NK-92 Cells and FDA-Approved Alefacept Can Selectively Target the Latent HIV Reservoir in CD4+ CD2hi Memory T Cells

Elimination of the latent HIV reservoir remains the biggest hurdle to achieve HIV cure. In order to specifically eliminate HIV infected cells they must be distinguishable from uninfected cells. CD2 was recently identified as a potential marker enriched in the HIV-1 reservoir on CD4+ T cells, the largest, longest-lived and best-characterized constituent of the HIV reservoir. We previously proposed to repurpose FDA-approved alefacept, a humanized α-CD2 fusion protein, to reduce the HIV reservoir in CD2hi CD4+ memory T cells. Here, we show the first evidence that alefacept can specifically target and reduce CD2hi HIV infected cells in vitro. We explore a variety of natural killer (NK) cells as mediators of antibody-dependent cell-mediated cytotoxicity (ADCC) including primary NK cells, expanded NK cells as well as the CD16 transduced NK-92 cell line which is currently under study in clinical trials as a treatment for cancer. We demonstrate that CD16.NK-92 has a natural preference to kill CD2hi CD45RA- memory T cells, specifically CD45RA- CD27+ central memory/transitional memory (TCM/TM) subset in both healthy and HIV+ patient samples as well as to reduce HIV DNA from HIV+ samples from donors well controlled on antiretroviral therapy. Lastly, alefacept can combine with CD16.NK-92 to decrease HIV DNA in some patient samples and thus may yield value as part of a strategy toward sustained HIV remission.

Can We Repurpose FDA-Approved Alefacept to Diminish the HIV Reservoir?

Current anti-retroviral treatment (ART) for HIV is effective in maintaining HIV at undetectable levels. However, cessation of ART results in immediate and brisk rebound of viremia to high levels. This rebound is driven by an HIV reservoir mainly enriched in memory CD4+ T cells. In order to provide any form of functional HIV Cure, elimination of this viral reservoir has become the focus of current HIV cure strategies. Alefacept was initially developed for the treatment of chronic plaque psoriasis. Alefacept is a chimeric fusion protein consisting of the CD2-binding portion of human leukocyte function antigen-3 (LFA3) linked to the Fc region of human IgG1 (LFA3-Fc). Alefacept was designed to inhibit memory T cell activation that contributes to the chronic autoimmune disease psoriasis by blocking the CD2 coreceptor. However, it was found to deplete memory T cells that express high levels of CD2 via NK cell-mediated antibody dependent cell cytotoxicity (ADCC) in vivo. Phase II and phase III clinical trials of alefacept with psoriasis patients demonstrated promising results and an excellent safety profile. Subsequently, alefacept has been successfully repurposed for other memory T cell-mediated autoimmune diseases including skin diseases other than psoriasis, organ transplantation and type I diabetes (T1D). Herein, we review our specific strategy to repurpose the FDA approved biologic alefacept to decrease and hopefully someday eliminate the HIV reservoir, for which CD2hi memory CD4+ T cells are a significant contributor.

Fc-fusion proteins and FcRn: structural insights for longer-lasting and more effective therapeutics

Nearly 350 IgG-based therapeutics are approved for clinical use or are under development for many diseases lacking adequate treatment options. These include molecularly engineered biologicals comprising the IgG Fc-domain fused to various effector molecules (so-called Fc-fusion proteins) that confer the advantages of IgG, including binding to the neonatal Fc receptor (FcRn) to facilitate in vivo stability, and the therapeutic benefit of the specific effector functions. Advances in IgG structure-function relationships and an understanding of FcRn biology have provided therapeutic opportunities for previously unapproachable diseases. This article discusses approved Fc-fusion therapeutics, novel Fc-fusion proteins and FcRn-dependent delivery approaches in development, and how engineering of the FcRn-Fc interaction can generate longer-lasting and more effective therapeutics.

Off-label biologic regimens in psoriasis: a systematic review of efficacy and safety of dose escalation, reduction, and interrupted biologic therapy

OBJECTIVES

While off-label dosing of biologic treatments may be necessary in selected psoriasis patients, no systematic review exists to date that synthesizes the efficacy and safety of these off-label dosing regimens. The aim of this systematic review is to evaluate efficacy and safety of off-label dosing regimens (dose escalation, dose reduction, and interrupted treatment) with etanercept, adalimumab, infliximab, ustekinumab, and alefacept for psoriasis treatment.

DATA SOURCES AND STUDY SELECTION

We searched OVID Medline from January 1, 1990 through August 1, 2011 for prospective clinical trials that studied biologic therapy for psoriasis treatment in adults. Individual articles were screened for studies that examined escalated, reduced, or interrupted therapy with etanercept, adalimumab, infliximab, ustekinumab, or alefacept.

DATA SYNTHESIS

A total of 23 articles with 12,617 patients matched the inclusion and exclusion criteria for the systematic review. Data were examined for primary and secondary efficacy outcomes and adverse events including infections, malignancies, cardiovascular events, and anti-drug antibodies. The preponderance of data suggests that continuous treatment with anti-TNF agents and anti-IL12/23 agent was necessary for maintenance of disease control. Among non-responders, dose escalation with etanercept, adalimumab, ustekinumab, and alefacept typically resulted in greater efficacy than standard dosing. Dose reduction with etanercept and alefacept resulted in reduced efficacy. Withdrawal of the examined biologics led to an increase in disease activity; efficacy from retreatment did not result in equivalent initial response rates for most biologics. Safety data on off-label dosing regimens are limited.

CONCLUSION

Dose escalation in non-responders generally resulted in increased efficacy in the examined biologics used to treat moderate-to-severe psoriasis. Continuous treatment with anti-TNF agents and anti-IL12/23 agent results in superior efficacy over interrupted therapy. The decision to use off-label dosing needs to account for both benefits and risks and be individualized to patients' disease severity, quality of life, and existence of comorbidities.

Selective targeting of human alloresponsive CD8+ effector memory T cells based on CD2 expression

Costimulation blockade (CoB), specifically CD28/B7 inhibition with belatacept, is an emerging clinical replacement for calcineurin inhibitor-based immunosuppression in allotransplantation. However, there is accumulating evidence that belatacept incompletely controls alloreactive T cells that lose CD28 expression during terminal differentiation. We have recently shown that the CD2-specific fusion protein alefacept controls costimulation blockade-resistant allograft rejection in nonhuman primates. Here, we have investigated the relationship between human alloreactive T cells, costimulation blockade sensitivity and CD2 expression to determine whether these findings warrant potential clinical translation. Using polychromatic flow cytometry, we found that CD8(+) effector memory T cells are distinctly high CD2 and low CD28 expressors. Alloresponsive CD8(+) CD2(hi) CD28(-) T cells contained the highest proportion of cells with polyfunctional cytokine (IFNγ, TNF and IL-2) and cytotoxic effector molecule (CD107a and granzyme B) expression capability. Treatment with belatacept in vitro incompletely attenuated allospecific proliferation, but alefacept inhibited belatacept-resistant proliferation. These results suggest that highly alloreactive effector T cells exert their late stage functions without reliance on ongoing CD28/B7 costimulation. Their high CD2 expression increases their susceptibility to alefacept. These studies combined with in vivo nonhuman primate data provide a rationale for translation of an immunosuppression regimen pairing alefacept and belatacept to human renal transplantation.

Alefacept: where it stands today

IMPORTANCE OF THE FIELD

The use of biologics that target a subset of immune cells in the treatment of immune-mediated ailments is an emerging field. Alefacept is one of the first biologics in the treatment of psoriasis. It selectively reduces CD45RO(+) memory T cells and inhibits T-cell activation. Clinical data support its safety and efficacy in a substantial subset of patients with psoriasis.

AREAS COVERED IN THIS REVIEW

This article reviews the mechanism of action and the pharmacokinetic and pharmacodynamic properties of alefacept. It also presents the available data about its effectiveness, modes of treatment as well as safety and efficacy in the treatment of psoriasis and other immune-based dermatologic disorders.

WHAT THE READER WILL GAIN

An overview of the published data about the clinical and adverse effects of alefacept in the treatment of psoriasis and a myriad of immunologically-based disorders.

TAKE HOME MESSAGE

Ongoing literature supports that alefacept is a safe alternative for the treatment of psoriasis. However, it remains the least prescribed medication in this group of drugs, mainly because it is only effective in a small proportion of patients. Nonetheless, its long-lasting effects and tolerability make it an excellent choice for those who do respond.

Update on Alefacept Safety

Background:

Alefacept has been demonstrated in clinical trials to be an effective, safe, and well-tolerated treatment strategy when used alone or in combination with other antipsoriatic therapies in patients with chronic plaque psoriasis.

Objective:

AWARE (Amevive Wisdom Acquired from Real-World Evidence) is a multicenter, observational, Canadian phase IV registry evaluating the efficacy and safety of alefacept, alone or in combination with other antipsoriatic therapies, in patients with psoriasis.

Methods:

Patients with chronic plaque psoriasis were treated with at least one course of alefacept followed by an off-treatment period, typically lasting 12 or more weeks. Prospective follow-up was at least 60 weeks, depending on when patients presented for retreatment. Safety data collected throughout the study included the incidence of serious adverse events (SAEs), dosing suspensions, and withdrawals owing to adverse events.

Results:

Twelve SAEs were reported in psoriasis patients treated with at least one course of alefacept, with only one considered to be possibly related to the study drug. Approximately one-quarter of patients missed at least one dose of alefacept during the course of the study. A total of 291 doses of alefacept were missed, representing almost 4% of the total doses administered in this group of patients. Low CD4+ count was the most frequent reason for missed doses; however, no patient had persistently low CD4+ counts requiring permanent discontinuation of alefacept treatment. Seven patients in the AWARE registry discontinued treatment with alefacept, with the most common reason being patient request.

Conclusion:

The AWARE study supports the safety of alefacept used alone or in combination with other antipsoriatic therapies, in a broad population of real-world chronic plaque psoriasis patients in Canada.

Biologics in the management of psoriasis

Psoriasis is a chronic inflammatory systemic disease for which there exist topical, ultraviolet, systemic, and biologic treatments. Biologic agents selectively interfere with the immune mechanisms responsible for psoriasis. Etanercept, infliximab, and adalimumab target tumor necrosis factor-alpha and have demonstrated efficacy in the treatment of psoriasis and psoriatic arthritis. Alefacept and efalizumab target T lymphocytes, are effective in the treatment of psoriasis, but are not approved for psoriatic arthritis. Finally, ustekinumab and ABT-874 target interleukin-12 and interleukin-23, and they have demonstrated efficacy in the treatment of psoriasis. The objective of this review is to present efficacy and safety data from randomized controlled trials of the biologic agents in the treatment of psoriasis.

The effect of topical corticosteroids in combination with alefacept on circulating T‐cell subsets in psoriasis

BACKGROUND

Novel therapies against psoriasis are emerging. Alefacept is such a treatment. It selectively targets the memory effector population of T cells and thereby diminishes the psoriatic plaques. In some cases, however, the use of alefacept as a monotherapy is not sufficient.

OBJECTIVE

In the present study we investigate the safety and efficacy of adding topical steroids to alefacept treatment during the initial 4 weeks.

METHODS

Peripheral blood was obtained from all patients and the presence of specific T-cell subsets was assessed by flow cytometry. Fourteen patients were included and treated with 15 mg alefacept intramuscularly for a period of 12 weeks. Each of them was randomized to use either betamethasone-dipropionate cream or a vehicle cream during the first 4 weeks of the alefacept course.

RESULTS

Additional topical corticosteroid treatment during the first 4 weeks of alefacept treatment does not have a beneficial effect on the clinical efficacy. Marked changes were seen in the absolute cell counts of various of the analysed T-cell subsets in peripheral blood after 12 weeks of alefacept, either with or without additional local steroid application. The CD45RO+, CD8+CD45RO+, CD8+CD161+, CD4+CD25+, CD4+CLA+ and CD8+CLA+ populations showed a statistically significant decrease immediately after the treatment period. Further analysis revealed that the addition of local steroid therapy to alefacept results in marked decreases of all T-cell subsets analysed in this study, in contrast to the addition of the vehiculum only.

CONCLUSION

Alefacept selectively targets the CD45RO+ lymphocyte population, as well as some other subpopulations of lymphocytes. This effect is independent of the use of additional topical therapy during the first 4 weeks. The extent of the decrease, on the contrary, is dependent on the use of corticosteroids.

Alefacept in the treatment of psoriasis

Alefacept is the first biologic agent approved by the US Food and Drug Administration for the treatment of psoriasis. To date, more than 1000 patients with moderate to severe psoriasis have been enrolled in phase III clinical trials of alefacept. More than 30% of patients treated with 2 courses of alefacept reached a Physician's Global Assessment of clear to almost clear, and approximately 40% and 70% of patients achieved a Psoriasis Area Severity Index score of 75 and 50 after the same regimen. Alefacept is well tolerated, and there have been no reports of significant systemic toxicity or serious treatment-related adverse events.

A multicenter, open-label study of repeat courses of intramuscular alefacept in combination with other psoriasis therapies in patients with chronic plaque psoriasis

OBJECTIVE

To evaluate the safety and efficacy of multiple courses of alefacept in combination with traditional psoriasis therapy for the treatment of chronic plaque psoriasis (CPP).

METHODS

Patients with CPP requiring systemic therapy were eligible for this study. Patients received up to three courses of intramuscular alefacept 15 mg once weekly for 12 weeks. One concomitant psoriasis therapy (topical agents, methotrexate, cyclosporine, systemic retinoids, or ultraviolet B [UVB]) per course was allowed. The extent of disease was determined using the 7-point Physician Global Assessment (PGA; scale ranging from 0 = clear to 6 = severe).

RESULTS

More than 73% of patients improved by > or = one PGA category and > or = 44% of patients improved by > or = two PGA categories across all concomitant treatments. Clinical responses tended to be greatest in patients who received alefacept plus UVB. The incidences of serious infections (< or =1%) and malignancies (< or =2%) were low across all courses and all combinations.

CONCLUSION

Multiple courses of alefacept appear to be well tolerated and demonstrate efficacy in patients with CPP when administered with other psoriasis therapies.

Perioperative management of medications for psoriasis and psoriatic arthritis: a review for the dermasurgeon

BACKGROUND

Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery.

OBJECTIVES

The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures.

CONCLUSIONS

This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

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.

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.

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.

An integrated analysis of thirteen trials summarizing the long-term safety of alefacept in psoriasis patients who have received up to nine courses of therapy

BACKGROUND

Information on longer-term safety and tolerability is needed to confidently prescribe alefacept therapy for chronic plaque psoriasis beyond 1 or 2 courses.

OBJECTIVE

The aim of this work was to further examine the safety profile of alefacept by integrating data from clinical trials involving patients with chronic plaque psoriasis who received up to 9 courses of therapy over a 5-year period.

METHODS

Data from 13 clinical trials conducted in patients with plaque psoriasis were integrated because they had similar inclusion/exclusion criteria and assessments. Patients who enrolled in the analyzed trials were aged > or =15 years with chronic plaque psoriasis for > or =12 months that involved > or =10% of body surface area, and CD4+ T lymphocyte counts above the lower limit of normal (>404 cells/microL). The incidences of adverse events (AEs), serious AEs, discontinuations for AEs, infections, serious infections, malignancies, and anti-alefacept antibodies were summarized for each course of alefacept. The incidence of infections was stratified according to CD4+ T lymphocyte counts (<250 cells/microL vs > or =250 cells/microL).

RESULTS

Data from 13 clinical trials of alefacept were integrated and summarized (multicenter, randomized, double-blind studies, n = 6; multicenter, open-label studies, n = 5; other, n = 2). The analyzed population (n = 1869) included 1291 (69.1%) men and 578 (30.9%) women, between the ages of 15 and 84 years (mean, 44.8 years), of whom 1648 (88.2%) were white. Weights ranged from 40 kg to 206 kg (mean, 90.0 kg). A total of 1369 of these patients had been included in a previous analysis. Among the most commonly reported AEs in each treatment course were headache (0%-14.2%), nasopharyngitis (7.7%-25.0%), influenza (0%-8.1%), upper respiratory tract infection (0%-12.5%), and pruritus (0%-7.5%). The rates of discontinuations due to AEs (0%-4.8%), serious AEs (0%-4.8%), serious infections (0%-0.9%), or malignancies (0%-4.8%) did not appear to increase with repeated exposure. Fewer than 1 % of patients in each course developed a serious infection. No opportunistic infections or infection-related deaths were reported. The incidence of infections appeared to be unrelated to CD4+ T lymphocyte counts. Fewer than 2.5% of patients tested positive for anti-alefacept antibodies during any course of therapy.

CONCLUSIONS

This integrated analysis of data from 13 trials with 1869 patients supports the safety and tolerability of alefacept for longer-term treatment of psoriasis.

The cost-effectiveness and cost of treatment failures associated with systemic psoriasis therapies

BACKGROUND

Psoriasis is difficult at times to treat and treatment failures are not uncommon regardless of approach. With the advent of expensive biologic therapies for psoriasis there is increasing discussion on the cost efficacy of a given systemic or biologic agent. An alternative and overlooked aspect of cost efficacy is the cost that accrues from treatment failures.

METHODS

We review the literature and develop a model to analyze the cost-effectiveness and the cost of treatment failures per success for various systemic psoriasis agents using a 12-week treatment period.

RESULTS

For continuous-dose agents, the cost-effectiveness results are: methotrexate $623, acitretin $2729, cyclosporine $2969, nUVB $3692, PUVA $4668, etanercept $16 312, and efalizumab $17 196. The cost of expected treatment failures to achieve one success for the same agents were: methotrexate $187, cyclosporine $505, PUVA $767, nUVB $1034, acitretin $1310, etanercept $8319, and efalizumab $12 897.

CONCLUSIONS

Methotrexate appears to be the most cost-effective agent for the treatment of severe psoriasis. However, greater efficacy can be achieved with cyclosporine and PUVA, albeit at a greater cost. Because of the high cost of treatment failures, access to a wide array of therapies and combination regimens should not be discouraged by physicians or insurers.

The efficacy of multiple courses of alefacept in patients with moderate to severe chronic plaque psoriasis

Among patients with psoriasis who did not achieve Psoriasis Area and Severity Index 50 during the first course of alefacept therapy, 53% achieved Psoriasis Area and Severity Index 50 during the second course (odds ratio [95% confidence interval] vs placebo 2.30 [1.26-4.19]). Alefacept provided incremental efficacy over 5 successive 12-week treatment courses.

Alefacept: a safety profile

Alefacept is a selective immunomodulating, antipsoriatic drug that blocks the LFA-3/CD2 interaction necessary for the activation and proliferation of memory effector T cells by binding to CD2 expressed on the T cell surface. Because the CD4+ count is reduced by alefacept, it is recommended that this count be monitored on a regular basis to ensure that it does not drop below 250 cells/mul. Few side effects have been related to the use of alefacept that differ from placebo even when CD4+ counts drop below 250 cells/microl. The side effects that have been reported are minor and include: headache, nasopharyngitis, rhinitis, influenza, upper respiratory tract infections, pruritus, arthralgias, fatigue, nausea, accidental injury and increases in liver enzymes. Serious infections and malignancies do not appear linked to the use of alefacept. The percentage of patients who developed antibodies against alefacept is very low. Alefacept is a very safe biological therapy for moderate-to-severe chronic plaque psoriasis with few side effects reported. The utility of checking CD4 counts while administering alefacept for 12 weeks appears minimal.

The Use of Systemic Immune Moderators in Dermatology: An Update

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.

Current and investigational treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is now recognised as a progressively destructive inflammatory arthritis that can lead to joint deformity and functional disability. Early diagnosis and treatment with disease-modifying antirheumatic drugs (DMARDs) are necessary to control disease, particularly in patients with clinical factors and human leukocyte antigen markers predictive of progressive disease. However, there are few randomised controlled trials of the traditional DMARDs in PsA and none have demonstrated efficacy on axial manifestations or delay in radiological progression. The demonstration of raised levels of TNF-alpha in psoriatic skin and synovial tissue has provided a rationale for the application of biological agents in PsA. Furthermore, the recognition of the role of T-cell activation in both psoriasis and PsA has led to the therapeutic targeting of T lymphocytes, the results of which at this early stage are encouraging. This article reviews the studies of the most widely used traditional DMARDs in PsA followed by studies with leflunomide and the biological response modifiers, including TNF-alpha antagonists and T-cell-targeted therapies.

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

Alefacept is the first biologic therapy approved by the United States Food and Drug Administration for the management of patients with moderate-to-severe chronic plaque psoriasis. Alefacept is a fully human fusion protein with a dual mechanism of action inhibiting T-cell activation as well as selectively reducing memory T cells. More than 2000 psoriasis patients have been treated with alefacept in clinical trials. These studies reveal an excellent clinical response, with 33% of patients achieving a Psoriasis Area Severity Index (PASI) score of 75 and 57% of patients achieving a PASI 50 after one course of alefacept. Patients achieving both PASI 75 and PASI 50 have significant improvements in their quality of life. The best responders can have long remissions, and there is a tendency toward continued improvement with subsequent courses of alefacept. The safety profile over the short and intermediate term is excellent. Preliminary data regarding alternate dosing regimens, transitioning patients from conventional systemics to alefacept, and combining alefacept with ultraviolet light therapy will be highlighted. We also will discuss our practical approach to patient selection, CD4 monitoring, management of infections while on alefacept, as well as decisions regarding retreatment and combination therapy.

Alefacept: a review of the literature and practical guidelines for management

Alefacept is the first biologic agent approved for the treatment of chronic, moderate to severe plaque-type psoriasis. It is a fully human fusion toxin, which binds to CD2, blocks costimulatory signaling, and selectively induces apoptosis of activated memory T cells involved in the pathogenesis of psoriasis. Alefacept has a slow onset of action, peaking approximately 18 weeks after the first injection of a 12-week course. However, it has several important advantages over the existing conventional immunosuppressive therapies for psoriasis: it is associated with long remissions without the need for maintenance therapy; its efficacy improves with subsequent courses; and it has a high safety profile. This review summarizes the mechanism of action of alefacept and the results of the clinical trials, with special emphasis on efficacy, pharmacodynamic effects on circulating lymphocytes, and safety and tolerability. Current guidelines based on the best available data to date are also presented.

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

Psoriasis: immunopathogenesis and evolving immunomodulators and systemic therapies; U.S. experiences

BACKGROUND

Psoriasis is a chronic inflammatory skin disorder that is presently without a permanent cure. Up to 40% of patients with psoriasis also develop psoriatic arthritis. The mainstay armamentarium to treat psoriasis systemically includes methotrexate, cyclosporin and oral retinoids, all with significant potential for toxicity and the need for close laboratory supervision. The although the exact mechanism of psoriasis is still unclear, the involvement of T-cell-mediated cytokine expression in the aetiology of psoriasis is becoming clearer. The goal of modern treatment is to target such immune responses that lead to the formation of psoriatic plaques and psoriatic arthritis using selective immunomodulating pharmacotherapy. The advantages of these biological agents are less toxic systemic side-effect profiles that will improve the quality of life in psoriatic patients.

OBJECTIVES

This review article describes current and emerging selective immunotherapies and systemic therapies for the treatment of psoriasis, and will briefly discuss disease immunopathogenesis.

METHODS

Literature review.

RESULTS AND CONCLUSIONS

Given the role of the inflammatory immune responses in the pathogenesis of psoriasis, the goal of modern medicine and pharmacotherapy lies in the design and use of specific targets in cell-mediated immune reactions and the modulation of the expression of various inflammatory cytokines. The clinical evidence of efficacy of some of these new biological immunomodulatory agents from several U.S.-based research studies and clinical experiences is convincing.

Systemic therapies for psoriasis: understanding current and newly emerging therapies

The treatment of moderate to severe psoriasis is a rapidly expanding area. Recent insights into the pathogenesis of this disease as a T-cell mediated process has led to a greater understanding of the mechanisms of action of conventional FDA-approved systemic therapies such as methotrexate, cyclosporine, acitretin, and psoralen with ultraviolet A phototherapy. It has also led to the development of rationally targeted therapies against key components of the immune process critical in the generation of the psoriatic plaque. Safety and efficacy data from clinical studies of 4 biologic agents furthest along in their development are reviewed. These results are promising, adding to the armamentarium for treating this disease.