Switching biologics for psoriasis

Challenges and Future Trends in the Treatment of Psoriasis

Psoriasis is a chronic inflammatory skin disorder, and current treatments include topical therapies, phototherapy, systemic immune modulators, and biologics, aiming to alleviate symptoms and improve quality of life. However, challenges persist, such as adverse effects, treatment resistance, high costs, and variability in response among individuals. The future of psoriasis treatment shows promising emerging trends. New biologic agents targeting novel pathways, such as interleukin 23 inhibitors like mirikizumab, offer enhanced efficacy. Small molecule inhibitors like RORγt inhibitors and ROCK2 inhibitors provide additional treatment options. Combination therapies, including biologics with methotrexate, may improve treatment response. Advancements in topical treatments utilizing microneedles and nanoparticle-based carriers can enhance drug delivery and improve therapeutic outcomes. Biomarkers and multi-omics technologies hold potential for personalized treatment approaches, thus aiding in diagnosis, predicting treatment response, and guiding therapeutic decisions. Collaboration among researchers, clinicians, and industry stakeholders is crucial to translating these scientific breakthroughs into clinical practice. By addressing current challenges and exploring these promising trends, we can optimize psoriasis management and improve the lives of those affected by this chronic condition.

Regulation of biosimilar medicines and current perspectives on interchangeability and policy

Competition arising from the increasing availability of biosimilar medicines has resulted in healthcare savings and has provided greater patient access to high cost therapeutics in Europe. The biosimilar market in the USA is relatively new so the full impact of biosimilar availability remains to be seen. Educational initiatives relating to the use of biosimilar medicines are currently being undertaken by regulators, policy makers and industry. The debate on biosimilars has moved on from the appropriateness of the regulatory framework which governs their approval, to the practice of interchangeability. Interchangeability is an important issue for healthcare professionals but different definitions and regulatory frameworks exist in the USA and Europe. In the USA, an interchangeable biological product is a biosimilar which may be substituted by a pharmacist, subject to local State policies. The interchangeability of a biosimilar with its reference medicine will be evaluated by the United States Food and Drug Administration (FDA) in cases where approval as an 'interchangeable product' is sought. In contrast, the European Medicines Agency (EMA) does not assess or make recommendations on interchangeability, therefore, in Europe, interchangeability does not mean substitution but is generally physician-led or driven by national policy. This paper provides an overview of the regulation of biosimilar medicines. Challenges associated with the demonstration of interchangeability and practical considerations relating to switching are also discussed. Finally, we present policies that have been adopted to date in several European countries, the USA and Australia, which aim to promote the use of biosimilar medicines.

Interchangeability of Biosimilars: A European Perspective

Many of the best-selling 'blockbuster' biological medicinal products are, or will soon be, facing competition from similar biological medicinal products (biosimilars) in the EU. Biosimilarity is based on the comparability concept, which has been used successfully for several decades to ensure close similarity of a biological product before and after a manufacturing change. Over the last 10 years, experience with biosimilars has shown that even complex biotechnology-derived proteins can be copied successfully. Most best-selling biologicals are used for chronic treatment. This has triggered intensive discussion on the interchangeability of a biosimilar with its reference product, with the main concern being immunogenicity. We explore the theoretical basis of the presumed risks of switching between a biosimilar and its reference product and the available data on switches. Our conclusion is that a switch between comparable versions of the same active substance approved in accordance with EU legislation is not expected to trigger or enhance immunogenicity. On the basis of current knowledge, it is unlikely and very difficult to substantiate that two products, comparable on a population level, would have different safety or efficacy in individual patients upon a switch. Our conclusion is that biosimilars licensed in the EU are interchangeable.

An evolution in switching therapy for psoriasis patients who fail to meet treatment goals

Switching psoriasis treatment is a common, accepted practice that is used to improve disease management and improve patient outcomes (e.g., when patients are experiencing suboptimal efficacy and/or tolerability with a given therapy). Historically, switching treatment was often performed to limit patients’ cumulative exposure to conventional systemic agents (e.g., methotrexate, cyclosporine) with the goal of reducing end‐organ toxicity. However, the practice of switching treatments has evolved in recent years with the availability of highly effective and tolerable biologic agents. In current practice, near‐complete skin clearance with minimal side effects should be a realistic treatment goal for most patients with moderate‐to‐severe psoriasis, and consideration for switching therapies has shifted to become more focused on achieving maximum possible skin clearance, enhanced quality of life, and improved patient satisfaction. This review provides a discussion of recent guidance on switching psoriasis therapies, including initial considerations for when switching therapy may be advisable and challenges associated with switching therapy, along with an overview of published clinical studies evaluating outcomes associated with switching therapy. The goal of this review is to empower dermatologists to optimally manage their patients’ psoriasis by providing the tools needed to develop rational strategies for switching treatments based on the pharmacologic characteristics of available treatments and each patient's clinical needs and treatment preferences.

Reasons for Treatment Changes in Patients With Moderate to Severe Psoriasis

BACKGROUND

Psoriasis treatment involves multiple treatment arms. Treatment choice depends on many factors and may change, due to the chronicity of psoriasis.

OBJECTIVE

The purpose of our study is to explore reasons for treatment changes in patients with moderate to severe psoriasis.

METHODS

Ten charts of patients with moderate to severe psoriasis were reviewed. The medication changes and reasons for change were extracted. A "treatment change" was defined as switching between medication classes, adding or removing a medication class, or switching medications within the oral or biologic medication class.

RESULTS

Seventy-seven treatment changes were identified. On average, 1 treatment change occurred per year of follow-up. The most common reason for treatment change was inadequate disease control.

CONCLUSIONS

Inadequate disease control with current therapy is the most common reason a physician changes treatment for moderate to severe psoriasis. More efficacious treatments or ways to improve efficacy may help improve the long-term outcomes of psoriasis.

Anti-TNFα therapy in the management of psoriasis: experience of a state referral center

BACKGROUND

Psoriasis is a chronic immune-mediated disease, characterized by increased levels of TNFα. Anti-TNFα agents have revolutionized the treatment of severe psoriasis by targeting an important molecule involved in its pathogenesis.

OBJECTIVES

We report the experience of a state referral center that uses anti-TNFα agents for psoriasis.

METHODS

We conducted a retrospective case series. Seventy-four out of 120 patients met the inclusion criteria. Clinical and laboratory data was analyzed using the chi-squared, Wicoxon and McNemar's tests. Associations were considered statistically significant when p-value<0.05.

RESULTS

Forty-one subjects (55.40%) were male, with a mean age of 47.69 ± 14.99 years. Median disease duration and pre-treatment PASI were 14.0 months (IQR 9.0-20.0), and 13.55 points (IQR 8.5-20.32). Sixty patients (81.10%) had arthropathic psoriasis. Forty-six subjects (62.20%) had comorbidities; the most frequent was dyslipidemia (25.70%). In 55.40% of patients, insufficient response to conventional therapies was the principal indication for using anti-TNFα drugs. Clinical improvement occurred in 93.20% of cases, and the post-treatment PASI median was 0.0 points (IQR 0.0-0.0). Adverse effects occurred in 6.80% of patients. Infections and elevation of transaminases occurred in 28.40% and 8.10% of cases, respectively.

CONCLUSION

Post-treatment reduction in PASI was satisfactory and the occurrence of adverse effects was minor, mostly mild infusion effects and local reactions at drug administration sites.

The safety of switching between therapeutic proteins

INTRODUCTION

The approval of several biosimilars in the past years has prompted discussion on potential safety risks associated with switching to and from these products. It has been suggested that switching may lead to safety concerns. However, data is limited on the clinical effects of switching.

AREAS COVERED

In this review we provide an overview of data related to switching between human recombinant growth hormones, erythropoietins and granulocyte colony stimulating agents. We reviewed data from clinical trials, pharmacovigilance databases and an overview of the literature on the frequency of switching between these products. The review covers both switching between innovator products within the same product class and switching to and from biosimilars.

EXPERT OPINION

Data on the frequency of switching in clinical practice is scarce, but it seems most frequent for erythropoietins. We have found no evidence from clinical trial data or post marketing surveillance data that switching to and from different biopharmaceuticals leads to safety concerns.