Current status and future prospects for biologic treatments of psoriasis

Improvement effects of a novel Chinese herbal formula in imiquimod and IL-23-stimulated mouse models of psoriasis

BACKGROUND

Psoriasis is a long-term inflammatory skin disease. A novel herbal formula containing nine Chinese herbal medicines, named Inflammation Skin Disease Formula (ISDF), has been prescribed in clinics for decades.

AIMS

To investigate the efficacy and action mechanisms of ISDF on psoriasis using imiquimod (IMQ) and Interleukin-23 (IL-23)-induced models in mice and reveal the pharmacokinetics profile of ISDF in rats.

METHODS

Topical administration of IMQ and intradermal injection with IL-23 respectively induced skin lesions like psoriasis on the dorsal area of Balb/c and C57 mice. The mice's body weight, skin thickness, and psoriasis area and severity index (PASI) were assessed weekly. SD rats were used in the pharmacokinetics study and the contents of berberine and baicalin were determined.

RESULTS

The PASI scores and epidermal thickness of mice were markedly decreased after ISDF treatment in both models. ISDF treatment significantly decreased the contents of IL-17A and IL-22 in the serum of IMQ- and IL-23-treated mice. Importantly, ISDF markedly downregulated IL-4, IL-6, IL-1β, and tumor necrosis factor α (TNF-α) gene expression, and the phosphorylation of NF-κB p65, JNK, ERKs and MAPK p38 in IMQ-treated mice. The protein phosphorylation of Jak1, Jak2, Tyk2 and Stat3 was significantly mitigated in the ISDF-treated groups. The absorption of baicalin and berberine of ISDF through the gastrointestinal tract of rats was limited, and their distribution and metabolism in rats were also very slow, which suggested ISDF could be used in the long-term application.

CONCLUSIONS

ISDF has a strong anti-psoriatic therapeutic effect on mouse models induced with psoriasis through IMQ and IL-23, which is achieved by inhibiting the activation of the Jak/Stat3-activated IL-23/Th17 axis and the downstream NF-κB signalling and MAPK signalling pathways. ISDF holds great potential to be a therapy for psoriasis and should be further developed for this purpose.

Clinical and patient-reported outcomes from the first 4 years of a Psoriasis Biologics Registry in Singapore

Interim analysis of the National Skin Centre Singapore Psoriasis Biologics Registry (SINGPSOR) from August 2017 to May 2021, in which 58 patients were analysed, showing that those receiving biologic treatment had significantly more severe psoriasis based on PASI (Psoriasis Area and Severity Index), BSA (body surface area) and PGA (Physician Global Assessment) measures at baseline, demonstrated a statistically non-significant trend towards greater improvement with treatment, and had a lower percentage of adverse events compared to those receiving conventional systemic therapy. Future analyses of SINGPSOR, with larger sample size and longer follow-up, will be invaluable to further characterize these patients and their treatment outcomes.

Plaque psoriasis and morphea in a patient on ustekinumab: A case report

A large number of autoimmune and fibrosing conditions associated with psoriasis and morphea have been reported in the literature. Currently, the relationship between psoriasis and morphea is unknown, and the coexistence of these conditions is quite rare. Due to the few patients affected by both conditions, and the lack of knowledge concerning their pathogenic mechanisms, the cause behind this co-occurrence is poorly understood. Here, we present a case of morphea under a plaque of psoriasis in a patient managed on ustekinumab.

Normal mesenchymal stem cells can improve the abnormal function of T cells in psoriasis via upregulating transforming growth factor-β receptor

Psoriasis, a chronic inflammatory skin disease, is a refractory disorder. Previous studies have shown that the imbalance of the T-helper (Th)17/regulatory T cells (Treg) results in the immune imbalance of T cells in psoriatic patients, and that mesenchymal stem cells display an immunosuppressive role by promoting the differentiation of T cells into Treg, leading to a reduction in the proportion of Th17/Treg. Utility of mesenchymal stem cells is becoming a new approach for the treatment of immune disorders. Following co-culture of dermal mesenchymal stromal cells (DMSC) and CD3⁺ T cells with or without transforming growth factor (TGF)-β receptor inhibitor, the biological function and relative signal pathway of CD3⁺ T cells were assessed by flow cytometry, transwell, real-time polymerase chain reaction and western blotting, respectively. Normal DMSC were more potent than psoriatic DMSC in inhibition of CD3⁺ T-cell proliferation, and stimulation of CD3⁺ T-cell apoptosis than psoriasis DMSC. Moreover, normal DMSC decreased the ratio of Th17/Treg, while enhancing the immunosuppressive effect of Tregs on effector T cells. However, TGF-β receptor (TGF-βR) inhibitor attenuated the effect of normal DMSC on CD3⁺ T cells and Th17/Treg ratio. Additionally, the normal DMSC were more potent than the psoriatic DMSC in increasing TGF-β receptors and activation of TGF-β/SMAD pathway in psoriatic CD3⁺ T cells. In conclusion, normal DMSC can partially improve the biological function and immunosuppressive ability of psoriatic CD3⁺ T cells, possibly via upregulating the TGF-β receptors.

Contemporary treatment patterns in plaque psoriasis and psoriatic arthritis

Introduction

Psoriasis is a chronic inflammatory skin disease affecting about 2% of the general population. Although there are many treatment options, and new medications have been introduced, the disease is considered not curable, and it may seriously affect patients’ quality of life.

Aim

The authors present contemporary treatment patterns used by dermatologists in Poland to manage plaque psoriasis and psoriatic arthritis, particularly regarding systemic treatment. The authors also aimed to analyse how these treatment patterns are influenced by the guidelines of the Polish Dermatological Society.

Material and methods

The author’s questionnaire, consisting of 13 questions was used. It included demographic and professional characteristics of questioned dermatologists, as well as the assessment of the attitudes towards management of plaque psoriasis and psoriatic arthritis.

Results

A total of 132 dermatologists completed the questionnaire. Most of the specialists worked in out-patient clinics and private practices. The most commonly used topicals for psoriasis included: glucocorticosteroids, a combination of glucocorticosteroid and vitamin D analogue and salicylic acid. Regarding the treatment of psoriatic arthritis, most of the specialists declared using systemic therapy and a combination of systemic therapy and phototherapy. The majority of the respondents were particularly concerned with possible side effects or difficulties in qualifying and monitoring the patients, and less frequently on the cost of the therapy.

Conclusions

Observations suggest that 60% of physicians have some reservation to initiate systemic treatment in outpatient clinics, and they admit that they lack additional training. On the other hand, it seems also that the organization of systemic treatment in psoriasis may generate these difficulties and thus necessitate additional effort. Another factor could be the budget – not only regarding healthcare professionals, but also the patient, sometimes financing various investigations from private resources.

Network meta-analysis of biologic treatments for psoriasis using absolute Psoriasis Area and Severity Index values ≤1, 2, 3 or 5 derived from a statistical conversion method

BACKGROUND

In practice, the goal of treatment for patients with psoriasis is to achieve almost clear or clear skin and maintain disease control, regardless of baseline disease severity. However, identifying absolute Psoriasis Area and Severity Index (PASI) values for new treatment goals is challenging, as most clinical trials report relative PASI 50, 75, 90 or 100 improvements but rarely absolute PASI values achieved.

OBJECTIVE

Our objective was to illustrate a statistical conversion method that was developed to derive absolute PASI values from available clinical trial data on relative PASI improvements. The results of network meta-analyses (NMAs) based on these derived data were then compared with those of NMAs based on the corresponding relative PASI improvement data for selected biologics for moderate-to-severe psoriasis.

METHODS

The PASI statistical conversion method was applied to relative PASI improvement data for 11 biologic treatment regimens and placebo at 12 weeks using data from 50 published studies. The respective proportions of patients reaching absolute PASI values ≤1, 2, 3 or 5 were then calculated. Frequentist NMAs (Rücker method) were subsequently used to compare efficacy results across relative and absolute PASI data.

RESULTS

The ranking of included treatment regimens for patients achieving absolute PASI 0 to 8 was aligned with results for relative PASI scores (from 100 to 60) at end of induction therapy. Across the range of PASI scores considered, the most effective treatment regimens based on both absolute and relative PASI NMAs were brodalumab 210 mg every 2 weeks and ixekizumab 80 mg every 2 weeks, followed by guselkumab 100 mg every 8 weeks and risankizumab 150 mg every 12 weeks.

CONCLUSION

Data generated using this mathematical model will be useful to inform ongoing scientific discussions on treatment goals in the absence of primary absolute PASI data for all available treatments for moderate-to-severe plaque psoriasis.

An Anti-Inflammatory Poly(PhosphorHydrazone) Dendrimer Capped with AzaBisPhosphonate Groups to Treat Psoriasis

Dendrimers are nanosized, arborescent macromolecules synthesized in a stepwise fashion with attractive degrees of functionality and structure definition. This is one of the reasons why they are widely used for biomedical applications. Previously, we have shown that a poly(phosphorhydrazone) (PPH) dendrimer capped with anionic azabisphosphonate groups (so-called ABP dendrimer) has immuno-modulatory and anti-inflammatory properties towards human immune cells in vitro. Thereafter, we have shown that the ABP dendrimer has a promising therapeutic efficacy to treat models of acute and chronic inflammatory disorders in animal models. In these models, the active pharmaceutical ingredient was administered systematically (intravenous and oral administrations), but also loco-regionally in the vitreous tissue. Herein, we assessed the therapeutic efficacy of the ABP dendrimer in the preclinical mouse model of psoriasis induced by imiquimod. The ABP dendrimer was administered in phosphate-buffered saline solution via either systemic injection or topical application. We show that the topical application enabled the control of both the clinical and histopathological scores, and the control of the infiltration of macrophages in the skin of treated mice.

Cost per responder for guselkumab versus secukinumab in the United States based on a head-to-head trial of moderate to severe plaque psoriasis. J DERMATOL TREAT 2020;33:518-524. [PMID: 32479140 DOI: 10.1080/09546634.2020.1770172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Aims: To estimate cost per response (CPR) in the United States and number-needed-to-treat (NNT) among subjects receiving guselkumab or secukinumab for moderate to severe plaque psoriasis.Materials and methods: Results from ECLIPSE, a double-blind, head-to-head, 48-week study of guselkumab compared with secukinumab were used to estimate 48-week, annual induction, and maintenance year CPRs for Psoriasis Area and Severity Index (PASI) 75, 90, and 100 responses for all patients and for PASI 90 response in patients according to previous systemic treatment.Results: Week 48 PASI 90 response rates were 84.5% for guselkumab and 70.0% for secukinumab. The CPR for PASI 90 response at 48 weeks was $89,960 for guselkumab versus $110,977 for secukinumab, and for the maintenance year it was $77,109 for guselkumab versus $88,781 for secukinumab. The NNT for a PASI 90 response was 1.18 for guselkumab and 1.43 for secukinumab. CPR and NNT values were also lower for guselkumab than for secukinumab, for PASI 75 and PASI 100 for the three time periods, and for PASI 90 at 48-weeks, regardless of previous systemic treatment.Conclusions: Results from a head-to-head study showed that, compared with secukinumab, guselkumab had lower NNTs and CPRs for PASI 75, PASI 90, and PASI 100 responses.

Salvianolic acid B ameliorates psoriatic changes in imiquimod-induced psoriasis on BALB/c mice by inhibiting inflammatory and keratin markers via altering phosphatidylinositol-3-kinase/protein kinase B signaling pathway

Salvianolic acid B (SAB) is an active phytocomponent of a popular Chinese herb called Radix Salvia militiorrhiza with numerous biological properties. The anti-psoriasis activity of SAB was examined by evaluating various psoriasis inflammatory and keratin markers against imiquimod (IMQ)-induced psoriasis on BALB/c mice. Totally 50 healthy BALB/c mice were evenly divided into 5 groups including control, drug control (SAB; 40 mg/kg), IMQ-induced psoriasis (5%), IMQ exposure and treated with SAB (40 mg/kg), or standard methotrexate (MTX; 1 mg/kg). Mice supplemented with either SAB or MTX significantly lowered the values of psoriasis area severity index (PASI), erythema, scaling, skin thickness, inflammatory markers (interleukin [IL]-22/23/17A/1β/6) and lipid peroxidation product (malondialdehyde). Also, IMQ exposed BALB/c mice treated with SAB or MTX display lesser histopathological changes with enhanced antioxidant activities (catalase, superoxide dismutase). Moreover, the protein expression of keratin markers (K16 and K17) and phosphatidylinositol-3-kinase (PI3K)/protein kinase B (Akt) signaling proteins (pAkt/Akt and pPI3K/PI3K) were significantly downregulated after administration with SAB and MTX as compared with IMQ induced mice. Taking together, SAB and MTX significantly ameliorate psoriatic changes by inhibiting psoriatic inflammatory and keratin markers through abolishing PI3K/Akt signaling pathway. However, further studies (clinical trials) are needed to confirm the anti-psoriatic property of SAB before recommending to psoriasis patients.

Cost per response for guselkumab versus adalimumab in the United States using data from a head-to-head trial in moderate-to-severe plaque psoriasis

Aims: To estimate annual cost per response (CPR) in the US and number needed to treat (NNT) among patients receiving guselkumab or adalimumab treatment for moderate-to-severe plaque psoriasis (PsO).Materials and methods: Results from VOYAGE 1, a double-blind, placebo-controlled, head-to-head, 48-week study of guselkumab compared with adalimumab in patients with moderate-to-severe PsO were used to estimate annual CPR for Psoriasis Area and Severity Index (PASI) 75, 90, and 100 responses. Drug dosing followed US label recommendations and drug costs were based on US annual wholesale acquisition costs. Number needed to treat (NNT) and annual CPR analyses were estimated, and week 48 response rates were assumed to be maintained for both the induction and maintenance years.Results: Week-48 PASI 90 response rates were 76.3% for guselkumab and 47.9% for adalimumab. The CPR for PASI 90 in the induction year for guselkumab was $113,861 vs $151,226 for adalimumab. Both drugs had lower CPRs for PASI 90 in the maintenance year: $85,395 for guselkumab and $140,424 for adalimumab for adalimumab. The NNT for a PASI 90 response was 1.3 for guselkumab and 2.1 for adalimumab; CPRs and NNT were also lower for guselkumab than for adalimumab for PASI 75 and PASI 100 for both induction and maintenance years.Limitations and conclusions: In this analysis, extrapolating 48-week results from a single head-to-head study, guselkumab was more cost-effective with lower NNT than adalimumab in both the induction and maintenance years for PASI 75, PASI 90, and PASI 100 responses.

Pharmacodynamics OF TNF α inhibitors for the treatment of psoriasis

Introduction: The treatment of psoriasis with conventional topical therapies and disease-modifying anti-rheumatic drugs (DMARDs) is often linked to unsatisfactory outcomes and the risk of serious adverse events. Over the last decades, research advances in understanding the role of tumor necrosis factor alpha (TNF α) and other cytokines in the pathogenesis of psoriasis have driven the introduction of biologic agents targeting specific immune mediators in everyday clinical practice. TNF α inhibitors are a consolidated treatment option for patients with moderate-to-severe disease with remarkable efficacy and a reassuring safety profile.Areas covered: The PubMed database was searched using combinations of the following keywords: psoriasis, TNF α inhibitors, biologic therapy, pharmacodynamics, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects. The aim of this review is to describe the pharmacodynamic profile of anti-TNF α inhibitors, currently approved by the European Medicines Agency (EMA) for the treatment of psoriasis, focusing on related clinical implications, also in comparison to the new generation biological therapies targeting the interleukin 23/interleukin 17 axis.Expert opinion: Pharmacodynamics of TNF α inhibitors should be fully considered in planning patient's therapy strategies, especially in case of secondary failures, poor adherence to treatment, instable psoriasis, high risk of infection, pregnant or lactating women, metabolic comorbidities, coexistence of other immune-mediated inflammatory diseases.

Real-world comparative effectiveness of adalimumab, etanercept and methotrexate: a Swedish register analysis

BACKGROUND

The advent of biosimilars may render etanercept (ETN) and adalimumab (ADA) viable alternatives to methotrexate (MTX) as first-line systemics in psoriasis. However, real-world relative effectiveness data comparing ADA and ETN to MTX are limited.

OBJECTIVE

To estimate the relative effectiveness of ADA and ETN compared to MTX.

METHODS

We analysed data from DermaReg, a regional register in Stockholm, Sweden, to estimate drug survival and mean Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) during maintenance treatment.

RESULTS

A total of 524 patients initiated 727 treatment episodes with ADA, ETN or MTX. After adjusting for confounders, patients treated with ADA had better drug survival (HR: 0.67; P = 0.003), lower mean PASI (-2.0; P < 0.001) and lower mean DLQI (-0.9; P < 0.001) during maintenance treatment compared to patients treated with MTX. The results for ETN compared to MTX were mixed. After adjusting for confounding, there was no significant difference in drug survival (HR 1.23; P = 0.082), but patients on ETN had lower mean PASI (-0.7; P = 0.006) during maintenance treatment.

CONCLUSION

Adalimumab is superior to MTX in clinical practice whereas the relative effectiveness between ETN and MTX is less clear. This study also highlights the importance of appropriate confounding control in effectiveness analysis.

Correlation of Physician-Assessed Psoriasis Area and Severity Index Scores With Patient-Reported Psoriasis Symptoms and Signs Diary Scores Among Patients With Moderate-to-Severe Psoriasis: Results From VOYAGE 1 and VOYAGE 2 Studies

Background:

Patient-reported and clinician-determined outcomes do not always correlate in clinical trials for psoriasis, even among those with clear skin.

Objective:

To compare clinical responses with patient-reported outcomes among patients with psoriasis enrolled in 2 phase 3, double-blind, controlled trials of guselkumab (VOYAGE 1 and VOYAGE 2).

Methods:

Overall, 1432 patients randomized to guselkumab, placebo, or adalimumab at baseline were included in the pooled patient population; measures were assessed at baseline and week 16. End points included proportions of patients achieving 100% improvement in their Psoriasis Area and Severity Index (PASI 100) score and summary scores = 0 on the Psoriasis Symptoms and Signs Diary (PSSD). Proportions of patients with PSSD symptom/sign summary scores = 0 and mean PSSD summary scores were summarized by PASI 100 status. Association between PASI and PSSD scores were evaluated using Pearson correlation coefficients.

Results:

Among week-16 PASI 100 responders, 46.8% and 34.1% reported PSSD symptom and sign summary scores = 0, respectively, and 30.9% and 49.0% reported minimal symptoms/signs (scores = 1 to <10), respectively; mean scores (scale 0-100) were 6.4 for symptoms and 5.8 for signs. Among PASI 100 nonresponders, only 11.1% (symptoms) and 7.5% (signs) reported PSSD summary scores = 0; mean scores were 25.7 and 26.7, respectively. Correlation coefficients between overall PASI response and PSSD scores were 0.63 (symptoms) and 0.68 (signs; both P < .0001).

Conclusion:

While PASI and PSSD scores were highly correlated and most PASI 100 responders reported no/minimal symptoms or signs at week 16, substantial discrepancies were found between complete clearance from the clinician’s view versus symptom/sign-free status from patients’ perspectives.

Reformulations of well-known active ingredients in the topical treatment of psoriasis vulgaris can improve clinical outcomes for patients

Although the majority of patients with psoriasis vulgaris are treated exclusively with topical therapies, research to develop more effective topical therapies that are associated with higher patient satisfaction has lagged behind the development of systemic agents. The aim of this literature review was to determine whether there is documented evidence that applying an innovative approach to improving the formulation of active ingredients commonly used in the topical treatment of psoriasis can have a positive effect on clinical outcomes and patient-reported outcomes (PROs). The Embase and PubMed databases were searched for articles published between 2001 and 2016 that made direct head-to-head comparisons of different formulations of an active pharmaceutical ingredient (API), focusing on clinical outcomes and PROs. In total, 22 publications on APIs or API combinations met the eligibility criteria (19 head-to-head clinical trials, one pooled analysis, one health-economic modelling study and one systematic review). Significant clinical benefit associated with the use of a reformulated API over an older formulation was reported in three trials of clobetasol propionate, one trial of calcipotriol, three trials of betamethasone and five trials/pooled analyses of calcipotriol/calcipotriene + betamethasone dipropionate (Cal/BD) formulations. Significantly improved PROs associated with the use of a reformulated API over an older formulation were reported in three trials of clobetasol propionate, one trial of betamethasone valerate and two trials of Cal/BD formulations. These results demonstrate that the innovative reformulation of APIs used in the treatment of psoriasis can produce therapies that attain significantly improved clinical outcomes and PROs. This suggests that improvement in topical therapy for psoriasis need not only to be achieved by the identification of new targets and the development of new APIs, but that improvement in the vehicle used to deliver existing APIs has the potential to result in significant clinical and patient benefits.