Consistent control of psoriasis by continuous long-term therapy: the promise of biological treatments

Association between cardio-cerebrovascular disease and systemic antipsoriatic therapy in psoriasis patients using population-based data: A nested case-control study

The effect of antipsoriatic therapy on cardio-cerebrovascular disease (CCVD) is not well described. Thus, we performed a population-based nested case-control study to investigate the effect of systemic antipsoriatic therapy on CCVD in psoriasis patients. Using nationwide cohort data from the Korean National Health Insurance Claims database, newly diagnosed psoriasis patients were identified. Among the enrolled participants, postenrollment development of CCVD events (ischemic heart disease, myocardial infarction, cerebral infarction, and cerebral hemorrhage) was investigated. To evaluate the effect of systemic antipsoriatic therapy on CCVD risk, we calculated the proportion of the treatment period with systemic antipsoriatic therapy during the study period (PTP [%]: the sum of all systemic antipsoriatic therapy durations divided by total observation period). Among 251 813 participants, 6262 experienced CCVD events during the study period (CCVD group). Controls included 245 551 patients without CCVD history during the study period (non-CCVD group). The non-CCVD group had greater PTP than the CCVD group (CCVD 2.12 ± 7.92, non-CCVD 2.64 ± 9.64; P < 0.001). In multiple logistic regression analysis, PTP was inversely associated with the CCVD risk after adjusting for age, sex, diabetes, hypertension, and dyslipidemia. A 10% increase in PTP reduced CCVD risk by 0.96 (95% confidence interval 0.93 to 0.99). Reduced CCVD risk was robust for both conventional antipsoriatic therapy and biologics. Our study found that systemic antipsoriatic therapy use was inversely associated with CCVD risk in psoriasis patients. These findings suggested that systemic antipsoriatic therapy could reduce CCVD development in patients with psoriasis.

Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature

Oral systemic therapies are important treatment options for patients with moderate-to-severe psoriasis, either as monotherapy or in therapy-recalcitrant cases as combination therapy with phototherapy, other oral systemics or biologics. Long-term treatment is needed to maintain sufficient disease control in psoriasis, but continuous use of systemic treatments is limited by adverse events (AEs) and cumulative toxicity risks. The primary aim of this comprehensive literature review was to examine the long-term safety profiles of oral agents commonly used in the treatment of adults with psoriasis. Searches were conducted in EMBASE and PubMed up to November 2018, and 157 relevant publications were included. Long-term treatment with acitretin could be associated with skeletal toxicity and hepatotoxicity, although evidence for skeletal toxicity is mixed and hepatotoxicity is rare, particularly at low doses. Other safety issues include hyperlipidaemia and potential for teratogenicity up to 2-3 years after discontinuation of treatment. There is a paucity of data on long-term treatment with apremilast. Continued exposure to apremilast does not seem to increase the incidence of common AEs, such as gastrointestinal (GI) AEs, upper respiratory tract infections and headache, while the long-term risks for depression, suicidal thoughts and weight loss are unknown. Long-term ciclosporin treatment is associated with renal toxicity, hypertension, non-melanoma skin cancer, neurological AEs and GI AEs. Long-term methotrexate treatment is associated with hepatotoxicity, GI AEs, haematological toxicity, renal toxicity and alopecia. Finally, long-term treatment with fumaric acid esters (FAE) is associated with GI AEs, flushing, lymphocytopenia, proteinuria and elevated liver enzymes. Median drug survival estimates varied considerably: ~  2.9-9.7 months for apremilast; ~ 5.4 months for ciclosporin; ~ 8.6 months for acitretin; ~ 12.1-21.6 months for methotrexate; and ~  54.8 months for FAE. These long-term safety profiles may help to guide clinicians to select the optimal oral systemic treatment for the long-term treatment of psoriasis in adults.

Safety and tolerability of adalimumab for the treatment of psoriasis: a review summarizing 15 years of real-life experience

Biologic therapies like adalimumab are the gold standard for psoriasis treatment with efficacy and safety profiles allowing for long-term treatment. However, adalimumab cannot be used in all patients and may cause adverse drug reactions. This study reviews conditions that might limit the use of adalimumab under real-life conditions. Local injection site reactions affect 12-37% of patients but rarely require specific therapy. Dermatological adverse events (AEs) include the paradoxical psoriasis and tend to respond to adequate therapy without adalimumab discontinuation. Adalimumab increases the risk for infections; latent chronic infections like tuberculosis or hepatitis B/C impose the highest risk for serious AEs. However, administration of adalimumab may still be possible under appropriate monitoring or prophylactic therapy. Some studies indicate an increased risk of malignancies in patients with psoriasis exposed to adalimumab. Here, the causal relationship is unclear since both psoriasis and some first-line therapies increase the risk of malignancies. Depression frequently coincides with psoriasis and may respond to adalimumab as well. Cardiovascular diseases are contraindications for adalimumab, but evidence suggests that adalimumab may still be a treatment option. Overall AE rates range from 245 to 399 per 100 patient years (serious AEs: 6-23; death: 1-2). Thus, adalimumab is slightly less safe than ustekinumab and infliximab but exhibits superior effectiveness and drug survival. Adalimumab is safe for pregnant women during the first trimester, for children up to 4 years and for the elderly. Thus, in spite of several conditions that require specific attention, the favourable safety and tolerability of adalimumab for the treatment of psoriasis is confirmed.

Clinical potential of brodalumab in the management of psoriasis: the evidence to date

Brodalumab is an anti-IL-17 receptor monoclonal antibody currently in development for the treatment of moderate-to-severe plaque psoriasis. With many systemic psoriasis therapies to choose from, and several newer agents in development, physicians need up to date evidence for the use of these drugs. A PubMed search was conducted through August 1, 2014 to identify randomized controlled trials and systematic reviews of brodalumab for the treatment of psoriasis. Results of Phase I and II trials, as well as a few smaller studies, have provided promising data on efficacy, safety, health-related quality of life, pharmacokinetics, and changes in lesional skin. Early Phase III data continue to support the use of brodalumab as a potentially valuable option for the treatment of psoriasis.

Clinical and Therapeutic Evaluation of Patients with Moderate to Severe Psoriasis in Spain: The Secuence Study

BACKGROUND: Evaluation of disease severity is considered essential in the optimal management of psoriasis. OBJECTIVES: To describe the clinical characteristics and therapeutic profile of patients with moderate to severe psoriasis in Spain and to assess the impact of the disease on the patients' quality of life. MATERIALS AND METHODS: This was an observational, cross-sectional study carried out in 90 dermatology units in Spain in 2009. We included 442 patients diagnosed with moderate to severe psoriasis who had started treatment with systemic agents, phototherapy, and/or topical treatments between 2004 and 2006. RESULTS: More severe psoriasis was significantly associated with the following: longer disease duration; higher prevalence of concomitant disease; greater involvement of the nails, scalp, flexures, palms, and soles; and poorer quality of life. In the 5 years before the start of the study, 68% of the patients had received conventional systemic treatments, 39.1% biologic agents, and 22.3% phototherapy. At present, 57.5% of the patients are being treated with biologic agents, 32.6% with conventional systemic treatments, and 11% with phototherapy. CONCLUSIONS: Severity of psoriasis was associated with a marked impact on quality of life. Regardless of disease severity, psychiatric comorbidity was the strongest predictor of poor quality of life. On average, patients had received other treatments, such as conventional systemic treatments or phototherapy, for more than 2 years before switching to biologic agents for the first time.

Ustekinumab: an evidence-based review of its effectiveness in the treatment of psoriasis

Introduction:

Psoriasis is a chronic inflammatory skin disease affecting approximately 2% to 3% of the population worldwide. Discoveries over the past 3 to 5 years have significantly altered our view of psoriasis as primarily a T-cell mediated condition. The most recent research has demonstrated the essential role of specific cytokines in the development of this complex disease, including TNF-α, interleukin-23 (IL-23), and potentially, IL-22. These are all part of a newly defined autoimmune pathway directed by specialized T cells called Th17 helper T cells. Ustekinumab is a fully human monoclonal antibody that targets IL-12 and IL-23, thus targeting both Th1 and Th17 arms of immunity. It has a promising efficacy and safety profile that not only represents a valuable treatment alternative, but also a continuation in our constantly evolving understanding of this disorder.

Aims:

To review the emerging evidence supporting the use of ustekinumab in the management of moderate to severe plaque psoriasis.

Evidence review:

There is clear evidence that ustekinumab is effective in the treatment of moderate to severe psoriasis. Phase III trials (PHOENIX 1 and 2) demonstrated a statistically significant difference between Psoriasis Area and Severity Index (PASI) 75 responses achieved by patients receiving ustekinumab, given as a 45 mg or 90 mg subcutaneous injection every 12 weeks, than their placebo counterparts. Treatment with this novel agent resulted in a rapid onset of action, with over 60% of treated patients attaining Physician’s Global Assessment (PGA) scores of “cleared” or “minimal” by week 12. Quality of life assessments paralleled clinical improvements.

Clinical potential:

Ustekinumab is an effective and efficient therapeutic option for patients with moderate to severe psoriasis. Although further studies are required to establish ustekinumab’s place in the therapy of psoriasis, with its convenient dosing schedule and rapid onset of action, this drug could provide a great addition to the current therapeutic armamentarium available for psoriatic patients.

Long-term efficacy of biologics in the treatment of psoriasis: what do we really know?

Psoriasis is a chronic inflammatory condition that often requires life-long treatment. Conventional therapies have not fully met the needs of psoriatic patients, because of limited efficacy, adverse effects with cumulative use, and patient inconvenience. In the past decade, biologic immunotherapies have become accepted treatments for psoriasis as a result of perceived efficacy and safety on the part of patients and practitioners. However, most data on these medications come from relatively limited short-term trials. In this review, we will focus on the available long-term data on the efficacy of the biologic agents. We will emphasize the strengths and weakness of the available data of the biologic agents that are Food and Drug Administration (FDA)-approved for the treatment of moderate to severe psoriasis (alefacept, efalizumab,* etanercept, infliximab, and adalimumab), with the inclusion of a newer agent currently under FDA evaluation (ustekinumab).

Ustekinumab improves health-related quality of life in patients with moderate-to-severe psoriasis: results from the PHOENIX 1 trial

Background PHOENIX 1 was a phase III, randomized, double-blind, placebo-controlled study that demonstrated the long-term efficacy and safety of ustekinumab in patients with moderate-to-severe psoriasis. Objectives To assess the effect of ustekinumab maintenance therapy on health-related quality of life (HRQoL) in PHOENIX 1 patients. Patients and methods Patients (n = 766) were randomized to receive ustekinumab 45 mg (n = 255) or 90 mg (n = 256) at weeks 0 and 4 and every 12 weeks thereafter, or placebo (n = 255) at weeks 0 and 4 with crossover to ustekinumab at week 12. Ustekinumab-randomized patients achieving at least 75% improvement in Psoriasis Area and Severity Index (PASI) 75 at weeks 28 and 40 were re-randomized at week 40 to continue ustekinumab or be withdrawn until loss of therapeutic effect. HRQoL was assessed using the SF-36 and Dermatology Life Quality Index (DLQI). Results At baseline, more than 97% had a DLQI > 1 and the average DLQI was > 10, indicating a significant impact on patients' HRQoL. Significantly greater proportions of patients receiving ustekinumab 45 and 90 mg achieved a normalized DLQI score (< or = 1) compared with placebo (53.2%, 52.4% and 6.0%, respectively, both P < 0.001) at week 12 and achieved a clinically meaningful improvement (increase of at least five points) in SF-36 physical (23.1%, 33.7% and 15.6%) and mental (25.5%, 31.3% and 14.8%) component summary scores. At week 12, changes in individual DLQI and SF-36 domains were significantly better in each ustekinumab group vs. placebo (P < 0.001). The magnitude of improvement across SF-36 scales was greatest for the bodily pain and social functioning domains. Improvements in HRQoL were sustained with maintenance ustekinumab therapy through at least 1 year. Regression analysis showed that, after adjustment for improvement in PASI or Physician's Global Assessment (PGA), ustekinumab-treated patients demonstrated significant improvements in DLQI. Conclusions Ustekinumab improves HRQoL in patients with moderate-to-severe psoriasis. Patient-reported outcomes measured a treatment effect beyond that indicated by clinical measures.

Management of psoriasis

Psoriasis is common, affecting about 2-3% of the population, and has major effects on patients' quality of life. Psoriasis varies in its manifestations and in how patients perceive the condition. Successful treatment involves addressing the clinical, psychological, and social aspects of the disease. Treatment options include topical agents, phototherapy and systemic treatment. Topical treatments are only practical for a fairly limited area of involvement. Phototherapy is practical for larger areas of involvement, but office phototherapy treatments are inconvenient. Traditional systemic medications are limited by side effects. New biologic agents that target specific components of the immune system are the most recent addition to our list of medications and provide higher efficacy with an improved safety profile, albeit at a higher cost.

Psoriasis in the elderly

Psoriasis is one of the most common chronic skin diseases, and unprecedented increases in the elderly population will make diagnosis and management of geriatric psoriasis increasingly important. Management of psoriasis in the elderly requires consideration of several important factors. Many commonly prescribed drugs can precipitate psoriasis or aggravate pre-existing psoriasis. In addition, elderly patients are at increased risk of adverse drug reactions due to polypharmacy, adverse drug–drug interactions, adverse drug–disease interactions, incorrect use of medication and concomitant comorbidities. Psoriasis is a highly variable disease that requires individualized treatment. The major classes of topical medications include topical corticosteroids, coal tar preparations, calcipotriol, tazarotene and salicylic acid. Phototherapy, including narrowband ultraviolet B, photochemotherapy, psoralen ultraviolet A and excimer laser treatment, can be effective in properly selected patients. Systemic therapy for psoriasis in the elderly should be reserved for severe, extensive cases that have failed to respond to topical treatment, and may include methotrexate, systemic retinoids and immunotherapy.

Efalizumab in the treatment of chronic plaque psoriasis: experiences from the largest psoriasis treatment centre in Denmark

About 20-30% of patients with chronic plaque psoriasis have severe forms of the disease and require systemic treatment. The long-term use of conventional systemic therapies is limited by toxicity, and many patients are resistant to these treatments. New biological agents, such as efalizumab and infliximab, offer a more targeted approach than conventional therapies and are more suitable for long-term, continuous treatment. At our hospital, we started treating patients with efalizumab in 2003 as part of a clinical trial programme and report here our experiences with this agent in 31 patients we have treated over the last 3 years. Here we share our standard procedures for patient selection, screening and treatment initiation, and report the efficacy and safety of efalizumab in our patients. Several case studies are presented to illustrate specific points of interest, such as the use of efalizumab in unstable psoriasis and management of arthropathy events. Finally, we suggest a number of approaches that may help to maximize the chances of long-term success in patients receiving efalizumab. In our hands, efalizumab has proven to be an effective therapy in the majority of patients (> 70%). The majority of these patients move to continuous efalizumab therapy (77%), the longest duration of which is currently 18 months. The main advantage of efalizumab over tumour necrosis factor-blockers is the lower risk of serious side-effects. By devising and disseminating effective strategies for the management of patients receiving efalizumab therapy, we hope this treatment will offer patients a truly continuous, long-term solution to their disease.

Emerging drugs for psoriasis

Psoriasis is a chronic immune-mediated inflammatory skin disease characterised by abnormal keratinocyte differentiation and proliferation. The immunopathogenesis is complex and novel evidence shows the involvement of both innate and adaptive immune response. Type 1 T cells and their effector cytokines play a pivotal role. Several drugs under preclinical and clinical development for psoriasis are directed against the immune response, targeting activation or proliferation of T cells, their trafficking and skin-homing, or effector cytokines. Among these, great attention has been given to TNF-alpha, following the demonstration of effectiveness of anti-TNF-alpha biologicals, and to IFN-gamma inducers. Another appealing approach concerns drugs capable of inducing immunological tolerance. Progress made in the recognition of intracellular events has prompted the development of small molecules and oligonucleotides that can inhibit specific molecular targets. There is, however, a plethora of other emerging drugs, clearly suggestive of the current interest for psoriasis, which are briefly described in this paper.