The safety of systemic treatments that can be used for geriatric psoriasis patients: a review

Infection and infestation-related adverse events of biologics in psoriasis: insights from the Food and Drug Administration Adverse Event Reporting System (FAERS)

OBJECTIVE

The study aims to thoroughly assess the adverse events related to infections and infestations associated with biological agents used for psoriasis using the U.S. Food and Drug Administration's Adverse Event Reporting System (FAERS) database.

METHODS

We analyzed FAERS data from the first quarter of 2004 to the fourth quarter of 2023. The study included TNF-α inhibitors (etanercept, infliximab, adalimumab), IL-12/23 inhibitors (ustekinumab), IL-23p19 inhibitors (guselkumab), and IL-17 inhibitors (secukinumab, ixekizumab). We used disproportionality analysis and Bayesian methods to quantify the related adverse event (AE) signals.

RESULTS

Most AEs related to infections and infestations are already listed on the drug packaging labels. Notably, TNF-α inhibitors are associated with a significantly higher incidence of tuberculosis-related diseases compared to other biological agents. In contrast, IL-17 inhibitors show a greater variety and number of fungal infection-related AEs than their counterparts. Furthermore, our study has identified new potential AEs that require the attention of clinicians.

CONCLUSION

In clinical practice, it is advisable to monitor the risks of infections and infestations in patients receiving biological agents for psoriasis to enable early detection and intervention. Our findings highlight the need for further epidemiological investigations to establish causality and guide clinical practice in managing these risks effectively.

Reevaluating Biota Alteration: Reframing Environmental Influences on Chronic Immune Disorders and Exploring Novel Therapeutic Opportunities

Environmental mismatches are defined as changes in the environment that induce public health crises. Well known mismatches leading to chronic disease include the availability of technologies that facilitate unhealthy diets and sedentary lifestyles, both factors that adversely affect cardiovascular health. This commentary puts these mismatches in context with biota alteration, an environmental mismatch involving hygiene-related technologies necessary for avoidance of infectious disease. Implementation of hygiene-related technologies causes a loss of symbiotic helminths and protists, profoundly affecting immune function and facilitating a variety of chronic conditions, including allergic disorders, autoimmune diseases, and several inflammation-associated neuropsychiatric conditions. Unfortunately, despite an established understanding of the biology underpinning this and other environmental mismatches, public health agencies have failed to stem the resulting tide of increased chronic disease burden. Both biomedical research and clinical practice continue to focus on an ineffective and reactive pharmaceutical-based paradigm. It is argued that the healthcare of the future could take into account the biology of today, effectively and proactively dealing with environmental mismatch and the resulting chronic disease burden.

Moderate to Severe Psoriasis in Older Adults: Recommendations on Management from the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life, such as associated comorbidity, polypharmacy, and immunosenescence. This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years. The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature. Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt. The recommendations can help to improve management, outcomes, and prognosis for older adults with moderate to severe psoriasis.

[Translated article] Moderate to Severe Psoriasis in Older Adults: Recommendations on Management From the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life, such as associated comorbidity, polypharmacy, and immunosenescence. This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years. The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature. Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt. The recommendations can help to improve management, outcomes, and prognosis for older adults with moderate to severe psoriasis.

Treating psoriasis in the elderly: biologics and small molecules

INTRODUCTION

Psoriasis prevalence in the elderly is growing. It is estimated that 15% of elderly psoriasis patients suffer from moderate-to-severe disease, thus requiring systemic treatments. However, conventional systemic agents' use is limited due to contraindications and drug-interactions. Conversely, biologics and small molecules seem to be a valuable option, although the geriatric psoriasis population is frequently excluded from trials and shared guidelines are lacking.

AREAS COVERED

Relevant English literature (trials, real-life studies, case series, and reviews) regarding biologics and/or small molecules in the elderly were searched for up to January 17, 2022.

EXPERT OPINION

Treatment of moderate-to-severe psoriasis in the elderly may be challenging due to multiple comorbidities, polypharmacy, and increased risk of infections and cancers. However, new targeted therapies offer the possibility to perform a tailored-tail management, considering comorbidities, drug-interactions, and frailties which characterize this class of patients. Several real-world data support biologics and small molecules' efficacy and safety in the elderly with mainly no significant difference as compared to young adults. Elderly psoriasis patients' expectations are as high as those of their younger counterparts. Hence, they deserve the best therapeutic options according to their peculiarities for a long-term psoriasis remission and an improved quality of life.

Therapy of PsO in Special Subsets of Patients

Psoriasis is a chronic, inflammatory skin disease that may occur at any age, with a bimodal peak of incidence around the age of 16-20 years of age (early onset) and 57-60 years (late-onset). It is estimated that roughly 70% of patients develop the disease before the age of 40, which coincides with the reproductive years. Moreover, psoriasis is a chronic disease, meaning that, with increased life-duration expectancy, the number of patients affected with psoriasis aged over 65 years is going to increase and represent a big therapeutic challenge. Actually, no specific drug recommendation is available, based only on the age of the patients, while therapeutic prescription should take into account that elderly patients have more comorbidities than younger patients, with polypharmacy and an increased risk of drug interactions. Women with psoriasis are more likely to report a worse influence of the disease on their quality of life, and they are more susceptible to the development of depression. Furthermore, pregnancy and lactation represent a major contraindication to several systemic agents, and only a few studies exist providing the safety of certain drugs during these periods of life of a woman, such as certolizumab pegol. In this paper, we discuss systemic therapeutic strategies, including conventional and biological therapies, in a special subset of patients affected with moderate-to-severe psoriasis focusing on elderly patients and on female patients in fertile age, pregnancy, and lactation.

Management of Psoriatic Erythroderma (PsE) with Ayurvedic herbomineral preparations: A case report

Psoriatic Erythroderma (PsE) is a presentation of Erythroderma due to a history of psoriasis showing inflammation and exfoliation of epidermal skin characterized by erythema and scaling. There is no definite treatment in contemporary medical science but the principle-based Ayurvedic approach has been proved to be effective. We present a case of PsE treated for 3 months with Ayurvedic herbomineral preparations and dietary restrictions for non-vegetarian and dairy items. As per the Ayurvedic diagnostic view, the presented case is correlated with Audumbara Kushtha and Ekakushtha due to their intricate features. Thus, Ayurvedic approaches were directed to eliminate vitiated doshas responsible for acute exacerbation of Kushtha (∼dermatitis) and to maintain equilibrium among them. The patient was initially considered as a case of Saam stage of Kushtha with Pitta-Rakta-Vata predominance. Thus, management was planned into different domains-treatment of Saam stage of Kushtha, Vyadhipratyanika chikitsa (∼disease antagonistic treatment), Rasayana intervention (∼Immunomodulation therapy) and Ayurvedic drugs were given accordingly. The assessment was done based on subjective parameters and PASI score. The patient was followed for about one and half year without any complication and relapse. This case study shows PsE can be managed with an Ayurvedic approach and proper diet planning.

Anti-interleukin-23 for psoriasis in elderly patients: guselkumab, risankizumab and tildrakizumab in real-world practice

Background

Elderly patients (aged ≥ 65 years) represent an increasing proportion of patients with psoriasis and 15% of these have moderate to severe disease. Biologics are being used frequently in this group of patients even though safety and efficacy data are limited. In addition, owing to anti‐interleukin (IL)‐23 therapies being a relatively recent option, no data have been reported about their use in elderly patients with psoriasis.

Aim

To evaluate and compare the safety and efficacy of guselkumab, risankizumab and tildrakizumab in real‐world practice in elderly patients.

Methods

This was a single‐centre retrospective study that enrolled patients aged ≥ 65 years with moderate to severe plaque psoriasis, treated with guselkumab, risankizumab or tildrakizumab. The length of the study for each group depended on the drug (44 weeks for risankisumab, 40 weeks for guselkumab and 28 weeks for tildrakizumab, owing to its more recent availability in Italy).

Results

In total, 34 patients were enrolled (n = 20 on guselkumab; n = 8 on risankizumab; n = 6 on tildrakizumab). At Week 4, 29.4% reached 90% improvement in Psoriasis Area and Severity Index (PASI90) and 8.8% reached 100% improvement in PASI (PASI100); at Week 28, PASI90 and PASI100 was reached by 58.8% and 29.4%, respectively. At the final follow‐up (Week 40 or 44, depending on drug), data were available only for the risankizumab (Week 40) and guselkumab (Week 44) and groups, and showed that 71.4% of patients had reached PASI90 and 53.5% had reached PASI100. Four patients (11.7%) discontinued treatment. No significant differences were found between the three groups. The limitations of the study included its retrospective nature of the study, small sample size, and different numbers of patients and follow‐up duration for the different groups (highest for guselkumab, lowest for tildrakizumab).

Conclusion

The three anti‐IL‐23 therapies assessed are promising, safe and effective options in elderly patients, and there was no significant difference between them. However, more data are needed to confirm our results and to understand their role in the management of this group of patients.

Safety of Systemic Medications Among Older Adults With Psoriasis and Atopic Dermatitis: A Systematic Review of Observational Studies

BACKGROUND

Psoriasis and atopic dermatitis are common among older adults (≥65 years old), but clinical trials often exclude that population.

OBJECTIVE

To synthesize evidence from observational studies on the safety of systemic therapies (conventional or biologic) for psoriasis and atopic dermatitis among older adults in a systematic review.

METHODS

We searched MEDLINE and EMBASE (inception to October 31, 2019) and included observational studies reporting adverse events among older people treated with systemic therapy for psoriasis or atopic dermatitis. Outcomes were death, hospitalization, emergency department visits, infections, major cardiovascular events, renal toxicity, hepatotoxicity, and cytopenias. We assessed study quality using the Newcastle-Ottawa Scale.

RESULTS

We included 22 studies on treatment for psoriasis and 2 for atopic dermatitis. Most studies were small and non-comparative and 20 of 24 were low quality. Studies comparing safety between medications or medication classes or between older and younger adults did not show apparent differences but had wide confidence intervals around relative effect estimates. Heterogeneity of study design and reporting precluded quantitative synthesis.

CONCLUSIONS

There is scant evidence on the safety of conventional systemic and biologic medications for older adults with psoriasis or atopic dermatitis; older adults and their clinicians should be aware of this evidence gap.

Management of inflammatory rheumatic conditions in the elderly

The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.

Chronic immunosuppression in the mature patient

In the ever-aging population of the world, the field of geriatrics continues to grow in importance. As human beings age, the skin undergoes a unique array of changes that predispose it to a specific set of dermatoses, infections, and neoplasms. Some of these physiologic alterations are comparable to the changes that happen in immunosuppressed individuals. Given the importance of immunosuppressive medications in treatment of many common skin conditions, we have reviewed the current literature to assist the practicing clinician in using immunosuppressive medications in the geriatric population.

Psoriasis in elderly patients in the Côte d'Ivoire: socio-demographic, clinical, and therapeutic aspects, and follow-up

BACKGROUND

Psoriasis is a chronic, inflammatory, and recurrent dermatological disease. In the Côte d'Ivoire, it is about 0.75% of dermatology cases. Psoriasis care is challenging in elderly patients. We aimed to show its specificities related to the sociodemographic, clinical, and therapeutic aspects, and follow-up in geriatric patients.

METHODS

Cross-sectional and descriptive study over a period of 10 years (January 2004-December 2013).

RESULTS

The prevalence of patients 60 years of age and older was about 0.1% (47 of 46,623 cases). The average age was 67 ± 1 years ranging from 60 to 85 years. The sex ratio was 1 : 9 in favor of men. The average time course of psoriasis was 25 ± 2 months. Comorbidity was found in 27 cases (57.5%). The most observed type of psoriasis in our study was chronic plaque psoriasis in 51.1% of cases. We found severe cases of psoriasis in 25.5% of cases. More than 10% of the body surface area was affected in 27.6% of cases. We used topical treatments in the majority of cases (83%). The course of psoriasis under treatment was good in 63.8% of cases, and only 6.4% of cases were worsening.

CONCLUSION

Topical agents could be the first-line treatment in geriatric patients in poor countries. If necessary, systemic agents should be used by taking into account the severity of psoriasis, presence of comorbidity factors, immune system level, and lifestyle.