Tapering and discontinuation of systemic medications in psoriasis patients with low disease activity

Increasing Access to Effective Systemic Treatments in Patients with Moderate-to-Severe Psoriasis: Narrative Review

Psoriasis is a chronic, immune-mediated inflammatory disease with a worldwide prevalence ranging between 0.51 and 11.43%. It results in a large clinical and social burden, with patients frequently suffering from reduced quality of life, psychologic distress and debilitating comorbidities. Biologic agents are used to establish and maintain disease control in patients with moderate-to-severe psoriasis and are essential to improving quality of life. However, a substantial proportion of patients have limited access to therapy due to economics, health policies and clinical considerations, which creates clinical unmet needs that disadvantage both patients and healthcare professionals. Biosimilars are a cost-effective alternative to off-patent biologic therapies, and there is mounting evidence to suggest they offer a valuable pharmacoeconomic strategy to lower healthcare costs in patients with psoriasis. Furthermore, the introduction of biosimilars can increase the number of patients able to receive biologics, allowing these patients to be treated earlier in the disease course, potentially modifying the course of their disease and reducing the risk of comorbidities. In time, the emergence of additional data, particularly those related to long-term safety, efficacy in extrapolated indications and the effects of switching, should reassure physicians and help overcome the final hurdles for a wider implementation of biosimilars. This review aims to provide an overview of current treatment approaches for patients with moderate-to-severe psoriasis in the biosimilars era and explores both the current challenges and potential opportunities to improve access to high-quality, effective treatments.

Granzyme B in Autoimmune Skin Disease

Autoimmune diseases often present with cutaneous symptoms that contribute to dysfunction, disfigurement, and in many cases, reduced quality-of-life. Unfortunately, treatment options for many autoimmune skin diseases are limited. Local and systemic corticosteroids remain the current standard-of-care but are associated with significant adverse effects. Hence, there is an unmet need for novel therapies that block molecular drivers of disease in a local and/or targeted manner. Granzyme B (GzmB) is a serine protease with known cytotoxic activity and emerging extracellular functions, including the cleavage of cell-cell junctions, basement membranes, cell receptors, and other structural proteins. While minimal to absent in healthy skin, GzmB is markedly elevated in alopecia areata, interface dermatitis, pemphigoid disease, psoriasis, systemic sclerosis, and vitiligo. This review will discuss the role of GzmB in immunity, blistering, apoptosis, and barrier dysfunction in the context of autoimmune skin disease. GzmB plays a causal role in the development of pemphigoid disease and carries diagnostic and prognostic significance in cutaneous lupus erythematosus, vitiligo, and alopecia areata. Taken together, these data support GzmB as a promising therapeutic target for autoimmune skin diseases impacted by impaired barrier function, inflammation, and/or blistering.

Comparison of overall efficacy and safety of oral versus subcutaneous methotrexate in severe psoriasis

BACKGROUND

Subcutaneous (SC) methotrexate(MTX) is considered to be associated with a higher and predictable linear bioavailability as compared to oral MTX. Although various studies have reported SC MTX to be safe and effective in psoriasis, prospective head-to-head comparative trials on oral vs SC MTX are limited.

OBJECTIVE

To compare the efficacy and safety of SC versus oral MTX in severe psoriasis.

METHODS

It was a prospective, single-blinded, randomized controlled trial, in 100 eligible, adult patients of severe psoriasis randomized into two groups. Group-A(n=50)patients were started on oral MTX at full dose of 0.3 mg/kg/week (maximum 25 mg/week) given for 12 weeks or till achieving PASI90 [90% reduction in psoriasis area severity index (PASI) from baseline],whichever was earlier and group-B(n=50) patients received SC MTX in the same dose and duration. MTX was then tapered gradually at 5 mg every 2 weeks and stopped. All patients were followed-up for 24 weeks post-treatment with monthly assessment of PASI and dermatology life quality index (DLQI) scores.

RESULTS

Baseline demographic profiles of patients in both the groups were comparable. The mean± SD baseline PASI scores were; group-A: 15.1± 3.2 vs group-B:15.7±3.3 (p= 0.35).The number of patients that achieved PASI90 at or before 12 weeks of treatment was numerically higher in group-B (39/50, 78%) versus group-A (31/50, 62%; p= 0.08) and the time to achieve PASI90 was significantly lesser (p<0.001).Also, the percentage(%) decline in DLQI was significantly higher in group-B(p= 0.003). The overall side-effect profile was comparable between groups (p= 0.31), but the frequency of gastrointestinal side-effects were significantly less in group-B (p= 0.04). Among those patients who achieved a PASI90 response by week12, relapse rates were comparable during the subsequent24week follow-up period [group-A: 12/31 (39%), group-B: 11/39 (28%), p-value= 0.33].

CONCLUSION

SC MTX results in significantly faster achievement of PASI90 and greater reduction in DLQI as compared to oral MTX in patients who are candidates for systemic therapy with a comparable safety profile.

CLINICAL TRIAL REGISTRATION

CTRI/2018/01/011373, date of registration: 15 January, 2018; trial registered prospectively.