Biological treatments for paediatric psoriasis : a retrospective observational study on biological drug survival in daily practice in childhood psoriasis

Effectiveness of biologic therapies in children with palmoplantar plaque psoriasis: An analysis of real-life data from the BiPe cohorts

BACKGROUND

Palmoplantar plaque psoriasis is a frequent clinical subtype of childhood psoriasis. This study evaluated the effectiveness of biologic therapies in children with palmoplantar plaque psoriasis using data from the two Biological treatments for Pediatric Psoriasis (BiPe) cohorts.

METHODS

Data for all 170 patients included in the BiPe cohorts were analyzed. Data on the effectiveness (PGA, PASI between baseline and 3 months of treatment) of biologic therapies were then compared between children with palmoplantar plaque psoriasis (n = 20) and those with generalized plaque psoriasis (n = 136). Clinical and demographic data were also analyzed.

RESULTS

Children in the palmoplantar group were more likely to be male (p = .04), with an earlier age of psoriasis onset (p < .001), and more frequent nail involvement (p < .001). After 3 months of biologic treatment, mean PGA scores were higher in the palmoplantar group than in the generalized plaque psoriasis group (p = .004). In the palmoplantar group, continuation rates were higher for adalimumab than for etanercept or ustekinumab (p = .01). Primary inefficacy was a more frequent reason for stopping biologic therapies in the palmoplantar group (p = .01), and disease remission was less frequent (p = .05). Combined systemic and biologic therapies were more frequently used in palmoplantar plaque psoriasis (p < .001).

CONCLUSIONS

This study demonstrated the treatment-resistant nature of palmoplantar plaque psoriasis and indicated that adalimumab could be the most effective biologic treatment. Larger studies are needed to allow therapeutic algorithms for palmoplantar plaque psoriasis to be proposed in pediatric psoriasis management guidelines.

Biological therapies for the treatment of psoriasis in pediatrics

INTRODUCTION

Psoriasis is a multifactorial, immune-mediated condition with predominant skin involvement. It may develop at any age. In one-third of patients, the first symptoms of psoriasis start during childhood or adolescence. A marked impairment of the quality of life of patients and their caregivers is often associated.

AREAS COVERED

Databases including PubMed and Clinicaltrials.gov were used to identify clinical studies involving pediatric patients with psoriasis. In the last few years, the implementation of therapy with drugs targeting cytokines like interleukin (IL)-12/23 and IL-17A has expanded the number of available therapeutic options in pediatric psoriasis. This review focuses on the latest evidence on the clinical efficacy and safety profile of drugs licensed for severe pediatric psoriasis.

EXPERT OPINION

Increasing knowledge about the pathogenetic mechanisms underlying pediatric psoriasis is leading to an improvement in disease management. Effective treatment is crucial in patients affected with moderate to severe disease to reduce the burden of the disease and avoid stigmatization. The treatment of pediatric psoriasis remains challenging for specific clinical subtypes, when difficult areas are involved, after resistance to multiple treatments, and when psoriatic arthritis is associated. A personalized approach and a thorough understanding of the disease are required to advance pediatric psoriasis care.

Biologics in pediatric psoriasis

Psoriasis is a chronic inflammatory skin disorder with a chronic relapsing course. Biologics have revolutionized the treatment of adult psoriasis with higher efficacy and favorable safety profile. Recently, more studies have focused on the use of biologics in pediatric psoriasis, and several biologics have been approved for use therein. This review is divided into two sections: the first part focuses on real-world studies on the use of biologics in pediatric psoriasis and the second part summarizes the findings of other clinical trials related to biologics in pediatric psoriasis. Case reports have been excluded from this review. Several biologics were used for treating pediatric psoriasis and the efficacy is encouraging. According to the studies included in this review, anti-IL-12/23 and anti-IL-17A for treating pediatric psoriasis might have a better efficacy than anti-TNF-α, but more data are needed.

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part I: focus on pediatric patients

INTRODUCTION

Psoriasis management is challenging, especially in pediatric age for different factors. The introduction of biologic drugs and oral small molecules (OSM) revolutionized the armamentarium of available weapons in psoriasis treatment. Despite the use of these drugs in adult patients has been widely investigated, pediatric patients have often been unconsidered in clinical trials and real-life studies. However, the high efficacy and speed of action, the safety profile and the ease-to-use administration make these innovative drugs an invaluable therapeutic opportunity.

AREAS COVERED

The aim of this manuscript is to perform a review of the current literature examining data on the effectiveness and safety of biologic drugs and OSM for the management of psoriasis in pediatric patients in order to put the basis for universally shared treatment algorithm following available evidence. PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for the literature research.

EXPERT OPINION/COMMENTARY

Our review based on currently available evidence suggests biologics and OSM as an ideal treatment option for pediatric patients, with an excellent profile in terms of efficacy and safety as compared to traditional systemic drugs.

Patient Characteristics and Treatment Patterns in European Pediatric Patients with Psoriasis: A Real-World, Cross-Sectional Study

Introduction

This study evaluated patient characteristics and treatment patterns according to weight in pediatric patients with psoriasis in a real-world setting.

Methods

Primary care and specialist physicians treating pediatric patients with psoriasis aged 6–17 years in five European countries were surveyed in the 2019–2020 Adelphi Real World Pediatric Psoriasis Disease Specific Programme. At least two patients with current or previous biologic use were included per physician. Patient characteristics and treatment patterns were analyzed overall and for patients weighing 25–50 kg or more than 50 kg.

Results

Data from 772 patients weighing 25–50 kg and 1147 weighing more than 50 kg were analyzed. Median age at diagnosis was significantly less in lighter than heavier patients (10.0 vs. 14.0 years; p < 0.001), as was median disease duration (2.2 vs. 3.0 years; p < 0.001). Topical treatments were prescribed in 59.0% of patients overall (70.3% of lighter and 51.4% of heavier patients; p < 0.001), and were used to treat mild rather than moderate-to-severe psoriasis. Conventional systemic use was low (10.8% of patients overall) and predominantly for moderate-to-severe psoriasis. In this biologic-enriched sample, most biologics (78.2%) were prescribed in older (> 13 years) patients. Biologic use increased with line of therapy (6.6% of first-line, 18.0% of second-line, 33.7% of third-line, 44.7% of fourth-line treatments).

Conclusion

Biologics are predominantly prescribed in older (> 13 years) and heavier (> 50 kg) patients, with little first- or second-line use. The low use of biologics in European pediatric patients with psoriasis may represent an unmet treatment need, as topical or conventional systemic agents remain the main treatment option for moderate or severe psoriasis in these patients through the treatment pathway.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00761-7.

This study looked into types of treatments according to body weight in children with psoriasis, since approved dosing regimens for some treatments are based on body weight. Primary care and specialist physicians treating children with psoriasis aged 6–17 years in five European countries completed a survey. Patient information for those receiving specific types of psoriasis treatments were collected. Of the children included, 772 weighed 25–50 kg and 1147 weighed more than 50 kg. Most children received treatments applied to the skin, such as creams and ointments; this occurred in 70% of lighter patients and in 51% of heavier patients. Conventional treatments taken via the mouth were prescribed in a few patients (11% [overall]), while newer biologic drugs were taken to a greater extent in heavier (30%) than lighter (16%) patients. Most biologics (78%) were prescribed in older (> 13 years) patients. Biologic use increased with the number of failed previous treatments, comprising 7%, 18%, 34%, and 45% of first, second, third, and fourth treatments, respectively. We conclude that children with psoriasis who are treated with biologic drugs are predominantly older and heavier, and have more severe psoriasis. Prescriptions for biologics are given after many other treatments have been tried.

Effectiveness and Safety of Adalimumab, Etanercept and Ustekinumab for Severe Psoriasis in Children Under 12 Years of Age: A French-Italian Daily Practice Cohort (BiPe Jr)

INTRODUCTION

Biological therapies are valuable treatments for severe psoriasis. Children aged under 12 years are underrepresented in therapeutic trials for these drugs. The objective of the 'BiPe Jr' cohort study was to evaluate the drug survival, effectiveness, tolerance and switching patterns of biological therapies in children under 12 years of age with psoriasis.

METHODS

We conducted a multicentre retrospective study of children with psoriasis who received at least one injection of a biological agent, even off-licence, before the age of 12 years in France and Italy, collecting the data between April and August 2021. The data collected were from March 2012 up to August 2021.

RESULTS

In total, 82 children (mean age: 9.1 years; females: 61.0%) received 106 treatments. The drugs administered were adalimumab (n = 49), etanercept (n = 37), ustekinumab (n = 15), anakinra (n = 2), infliximab (n = 2) and secukinumab (n = 1). The most common form of psoriasis was plaque psoriasis (62.9%). The Physician Global Assessment and the Psoriasis Area Severity Index (PASI) scores decreased significantly from baseline to 3 months after treatment initiation for the three main biological drugs; PASI went from 14.1 ± 9.4 to 4.1 ± 11.3 for adalimumab (p = 0.001), 14.9 ± 9.3 to 5.1 ± 4.0 for etanercept (p = 0.002) and 11.6 ± 8.3 to 2.6 ± 2.2 for ustekinumab (p = 0.007). A trend towards higher 2-year maintenance rates was observed for ustekinumab and adalimumab, compared with etanercept (p = 0.06). 52 children discontinued their biological therapy, most frequently due to inefficacy (n = 28) and remission (n = 14). Seven serious adverse events (SAEs) were reported, including four severe infections.

DISCUSSION

Our analyses of drug survival and treatment patterns, combined with those of previous studies conducted in older children, indicate that there is a trend towards higher 2-year survival rates of ustekinumab and adalimumab. The SAEs identified were rare, but highlight the need for increased vigilance concerning infections. Overall, the biological therapies showed good effectiveness and safety profiles when used in daily practice for the treatment of young children with psoriasis.

Switching biologics in children with psoriasis: Results from the BiPe cohort

BACKGROUND

There is currently little information on switching biologics in pediatric psoriasis.

OBJECTIVE

To evaluate the real-world clinical practice and safety of switching biologics in the "Biological Treatments for Pediatric Psoriasis" (BiPe) cohort.

METHODS

Data for all 134 patients included in the BiPe cohort were analyzed. A further evaluation of the subpopulation of patients who switched from a first-line biologic to a second-line biologic was then conducted. Drug survival rates were also compared between biologics given as first-line or second-line agents.

RESULTS

Overall, 29 patients (female: 55%; mean age: 16.6 ± 3.0 years) switched between two biologics. Etanercept (ETN) was the first-line biologic used in 23 patients: 16 (69.6%) switched to adalimumab (ADA) and seven (30.4%) to ustekinumab (UST). Six patients received first-line ADA and switched to UST. Loss of efficacy (62.1%), primary inefficacy (20.7%), and parental choice (6.9%) were the main reasons for switching biologics. One (3.4%) of the switches was performed because of adverse events or intolerance. For UST and ADA, the 18-month drug survival rate did not differ according to whether the agent was given as a first-line or second-line biologic (UST: P = .24; ADA: P = .68). No significant differences in drug survival rates were observed between the three different switches (ADA to UST, ETN to ADA, and ETN to UST).

CONCLUSION

Our study provided key insights into the real-life clinical practice of switching biologics in pediatric psoriasis patients. However, more information and guidance on switching biologics in pediatric psoriasis are needed to improve real-life practice and outcomes.

Evolution of Drug Survival with Biological Agents and Apremilast Between 2012 and 2018 in Psoriasis Patients from the PsoBioTeq Cohort

Drug survival reflects treatment effectiveness and safety in real life. There is limited data on the variation of drug survival with the availability of systemic treatments with additional biological disease-modifying antirheumatic drugs (bDMARDs) or synthetic disease-modifying antirheumatic drugs (sDMARDs). The aim of this study was to determine whether the increasing number of available systemic treatments for psoriasis affects drug survival over time. Patients were selected from the PsoBioTeq cohort, a French prospective observational cohort enrolling patients with moderate to severe psoriasis. All patients initiating a first bDMARD or sDMARD were included. The primary outcome was comparison of drug survival over time. A multivariate Cox proportional hazard ratio model was computed. A total of 1,866 patients were included; 739 females (39%), median age 47 years. In the multivariate Cox model, no association was found between the calendar year of initiation and drug survival (hazard ratio) overlapping from 0.80 (0.42–1.52) to 1.17 (0.64–2.17), p = 0.633). In conclusion, drug survival in psoriasis is not affected by the year of initiation.

Treatment utilization and drug survival of systemic medications among commercially insured children with psoriasis

BACKGROUND/OBJECTIVES

Systemic medications and phototherapy are used to treat pediatric psoriasis, but real-world data on treatment utilization and persistence are limited. The study objective was to determine systemic and phototherapy treatment utilization and compare drug survival among systemics in pediatric psoriasis.

METHODS

Using United States commercial insurance claims data, a cross-sectional analysis was conducted to describe the prevalence of systemic treatment and phototherapy use among patients <18 years old with psoriasis. We compared drug survival among new users of methotrexate, adalimumab, etanercept, and ustekinumab using a retrospective cohort design.

RESULTS

Among 13 759 patients, 14.6% used systemic or phototherapy treatment during 2001-2016, with rising utilization of systemics over this period. Among 579 new users of methotrexate, adalimumab, etanercept, and ustekinumab, the median durations of the initial treatment course were 141 (IQR 59-314), 179 (79-339), 175 (90-419), and 216 (64-435) days, respectively (P = .04). Drug discontinuation was less likely among ustekinumab (HR 0.47 [95% CI 0.27-0.83]), etanercept (0.74 [0.59-0.92]), and adalimumab (0.75 [0.55-1.02]) initiators than methotrexate initiators after adjustment for sociodemographic factors and psoriatic arthritis. Drug survival differences were limited to systemic-naïve patients. Potential limitations include short follow-up and residual confounding.

CONCLUSIONS

Utilization of systemic therapies for pediatric psoriasis is increasing, but differences in drug survival exist.

Biologicals for moderate-to-severe plaque type psoriasis in pediatric patients

INTRODUCTION

Psoriasis affects around 2% of children in Europe. The majority of cases is readily managed with topical treatments using corticosteroids without or with calcipotriol. More resistant and extensive moderate-to-severe cases require UVA or UVB phototherapies or conventional systemic treatment including ciclosporin, acitretin and methotrexate. However, these therapies are associated with a low tolerability and potential cumulative long-term adverse effects and toxicities.

AREAS COVERED

About 15 years ago, the first biological appeared for the treatment of moderate-to-severe plaque type psoriasis in adult patients. Several years later, the first biologic treatment to be approved in children was etanercept, a soluble receptor that binds both tumor necrosis factor (TNF)-α and β followed by adalimumab, a monoclonal antibody against TNF-α, and currently by ustekinumab, a monoclonal IL12/23 p40 antagonist and, very recently, secukinumab and ixekizumab, both IL17 antagonists. All these biologic treatments brought significantly improved treatment results compared to light-based therapies and conventional treatments and present very good tolerance and safety profiles.

EXPERT OPINION

Due to their excellent efficacy and safety profiles ustekinumab, secukinumab and ixekizumab could currently be considered as a first-line treatment options for moderate-to-severe childhood and adolescent psoriasis requiring a systemic treatment.

Biologic Treatment Algorithms for Moderate-to-Severe Psoriasis with Comorbid Conditions and Special Populations: A Review

The emergence of data from clinical trials of biologics, the approval of new biologics, and our improved understanding of psoriasis pathogenesis have increased the therapeutic possibilities for the treatment of moderate-to-severe psoriasis. Biologics currently approved for the treatment of psoriasis include tumor necrosis factor inhibitors, interleukin (IL)-17 inhibitors, ustekinumab (an IL-12/23 inhibitor), and IL-23 inhibitors. Data from clinical trials and studies of the safety and efficacy of biologics provide essential information for the personalization of patient care. We discuss the benefits and disadvantages of biologics as a first-line treatment choice, update treatment recommendations according to current evidence, and propose psoriasis treatment algorithms. Our discussion includes the following comorbid conditions: psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, nonmelanoma skin cancer, lymphoma, and latent tuberculosis. We make evidence-based treatment recommendations for special populations, including pediatric patients, patients with coronavirus 2019 (COVID-19), and pregnant and breastfeeding patients with psoriasis. Ultimately, individualized recommendations that consider patient preferences, disease severity, comorbid conditions, and additional risk factors should be offered to patients and updated as new trial data emerges.

Perspectives on the pharmacological management of psoriasis in pediatric and adolescent patients

INTRODUCTION

Psoriasis affects about 0.5% of children and adolescents, it has a high impact of social life. Management can be difficult. The beginning of the 21st century has been an interesting period for the management of pediatric psoriasis, with access to new topical and systemic treatments including several biotherapies.

AREAS COVERED

Herein, we analyze the current therapeutic strategies for managing psoriasis in young patients, ranging from infants to adolescents, in a holistic approach. Usual treatment but also new galenics, new topical associations, and biological (anti-TNF-alpha, anti-interleukin 12/23, anti-interleukin 17) recently developed are presented. Results from clinical trials are detailed, but also real-world evaluations, and recent guidelines. Practical tips for day-to-day management are finally proposed.

EXPERT OPINION

Currently, we have a wide range of treatments, which we can adapt to all types of psoriasis, depending on the demands of the child and his parents. The near future also looks promising with new topical combinations, new oral therapies (apremilast) and biologics (anti-interleukin 23), as well as genetically targeted therapies for pustular psoriasis.

A Comparison of Psoriasis Severity in Pediatric Patients Treated With Methotrexate vs Biologic Agents

Importance

Few studies have compared the use of methotrexate and biologics, the most commonly used systemic medications for treatment of moderate to severe psoriasis in children.

Objective

To assess the real-world, 6-month reduction in psoriasis severity and long-term drug survival (rate and duration of adherence to a specific drug) of methotrexate vs biologics in plaque psoriasis in children.

Design, Setting, and Participants

A retrospective medical records review was conducted at 20 European and North American centers. Treatment response was based on site-reported Psoriasis Area and Severity Index (PASI) and/or Physician Global Assessment (PGA) scores at baseline and within the first 6 months of treatment. Participants included all 234 consecutively seen children with moderate to severe psoriasis who received at least 3 months of methotrexate or biologics from December 1, 1990, to September 16, 2014, with sufficient data for analysis. Data analysis was performed from December 14, 2015, to September 1, 2016.

Main Outcomes and Measures

PASI, with a range from 0 to 72 (highest score indicating severe psoriasis), and/or PGA, with a scale of 0 (clear), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), and 5 (very severe).

Results

Of 234 pediatric patients (103 boys [44.0%]; 131 girls [56.0%]) treated with methotrexate and/or biologics, 163 patients (69.7%) exclusively received methotrexate, 47 patients (20.1%) exclusively received biologics, and 24 children (10.2%) received methotrexate and biologics sequentially. Of the latter cohort, 23 children were treated initially with methotrexate. Mean (SD) age at initiation was 11.6 (3.7) years for methotrexate and 13.3 (2.9) years for biologics (73.2% for etanercept) (P = .002). Among patients evaluated by a scoring method at 6-month follow-up, 75% or greater improvement in PASI (PASI75) was achieved in 12 of 30 patients (40.0%) receiving methotrexate and 20 of 28 patients (71.4%) receiving biologics, and PGA was clear/almost clear (PGA 0/1) in 41 of 115 patients (35.6%) receiving methotrexate and 18 of 37 patients (48.6%) receiving biologics. Achieving PASI75 and/or PGA 0/1 between baseline and 6 months was more likely with biologics than methotrexate (PASI75: odds ratio [OR], 4.56; 95% CI, 2.02-10.27; P < .001; and PGA 0/1: OR, 2.00; 95% CI, 0.98-4.00; P = .06). Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect, -3.13; 95% CI, -4.33 to -1.94; P < .001; and PGA effect, -0.31; 95% CI, -0.56 to -0.06; P = .02). After 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9%, and for biologics, the rates were 83.4%, 64.3%, and 57.1%, respectively. Biologics were associated with a better confounder-corrected drug survival than methotrexate (hazard ratio [HR], 2.23; 95% CI, 1.21-4.10; P = .01). Discontinuation owing to lack of response was comparable (HR, 1.64; 95% CI, 0.80-3.36; P = .18).

Conclusions and Relevance

Methotrexate and biologics appear to be associated with improvement in pediatric psoriasis, although biologics seem to be associated with greater reduction in psoriasis severity scores and higher drug survival rates than methotrexate in the real-world setting. Additional studies directly comparing these medications should be performed for confirmation.

Optimal Management of Plaque Psoriasis in Adolescents: Current Perspectives

The skin is at the interface between the body and its environment and is therefore at the center of adolescent concerns during this period of identity formation and increased awareness of body image issues, and stigmatization. Managing an adolescent with psoriasis involves managing the illness and the individual during their transition from being an older child to a young adult. In addition to ensuring that the patient adheres to treatments and is engaged with the therapeutic strategy, dermatologists may also need to manage issues linked to unspoken suffering or conflicts between the adolescent and their parents, who are often present during consultations. The impact of psoriasis on the social interactions, school life and sexuality of the patients, together with the influence of the internet and social networks, also have to be taken into account. In this review, we summarize the epidemiologic, clinical, and therapeutic data available on psoriasis in adolescents, and propose specific management strategies, adapted to the 21st century, for patients in this age group.

Adalimumab in severe plaque psoriasis of childhood: A multi-center, retrospective real-life study up to 52 weeks observation

The objective of this study is to determine drug effectiveness and safety of the tumor necrosis factor-alpha blocker monoclonal antibody adalimumab in a real-life cohort of 54 children and/or adolescents with severe plaque psoriasis. Retrospective, multicenter analysis over a 52-week period is discussed in this study. Efficacy was determined by the percentage of patients achieving Psoriasis Area Severity Index (PASI 75) and PASI 90 at weeks 16, 24, and 52 and the response in biologic-naïve versus non-naïve patients. Safety was assessed by the number of patients experiencing at least one adverse event. At week 16, 29.6% of patients achieved a 90% PASI score reduction (PASI 90), while 55.5% of patients achieved a 75% PASI score reduction (PASI 75). Effectiveness was sustained through week 24, since PASI 90 response increased to 55.5% and PASI 75 response increased to 74.0% of patients. The PASI response rates did not differ between biologic-naïve and non-naïve patients. The drug was well tolerated and no serious infections were observed. Adalimumab was effective and safe in this cohort of children with severe plaque psoriasis in a 52-week observation. Effectiveness did not differ between biologic-naïve and non-naïve patients.

Evaluation of Children with Psoriasis from the BiPe Cohort: Are Patients Using Biotherapies in Real Life Eligible for Phase III Clinical Studies?

BACKGROUND

Phase III clinical trials of biotherapies for childhood psoriasis are designed for a selected population, which can differ from real-life patients.

OBJECTIVE

Our objective was to assess the proportion of children with psoriasis that received biotherapy in the biological treatments for pediatric psoriasis (BiPe) cohort that would be excluded from phase III clinical trials of these treatments.

METHODS

Data concerning initiation of the first biotherapy from all patients included in the BiPe cohort were analyzed. Ineligibility was assessed after applying the exclusion criteria used in the principal phase III trials of etanercept, adalimumab, and ustekinumab for childhood psoriasis.

RESULTS

Of the 134 patients included, 73 (54.5%) were ineligible for at least one randomized controlled trial based on one or more exclusion criteria. Amongst the 63 children treated with etanercept, 35 (55.5%) were ineligible: 22 because of the type of psoriasis, 12 because of concomitant treatment, and six because of psoriasis severity based on psoriasis assessment severity index (PASI) and physician global assessment (PGA) scores (PASI < 12 and PGA < 3). Amongst the 44 children treated with adalimumab, 32 (72.7%) were ineligible: 17 because of the clinical type of psoriasis, 12 because of psoriasis severity (PASI < 20 and PGA < 4), and seven because of concomitant treatment. Amongst the 27 children patients treated with ustekinumab, 12 (44.4%) were ineligible: eight because of psoriasis severity (PASI < 12 and PGA < 3), five because of the clinical type of psoriasis, and one because of concomitant treatment. Drug survival and the frequency of serious adverse events did not differ between eligible and ineligible patients.

CONCLUSION

The majority of children treated with biotherapies in real-life practice differ from those in phase III trials, most commonly because of the clinical type of their psoriasis, the disease severity being lower than required and the use of prior or concomitant psoriasis treatment. Efficacy and safety results from phase III clinical trials in selected populations may not sufficiently reflect what is seen in real life, thus results from real-life cohort studies are necessary.