Current and emerging biologic and small molecule systemic treatment options for psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis are chronic inflammatory diseases affecting the skin and joints, respectively. Psoriasis and psoriatic arthritis are associated with a high comorbidity burden as well as negative impact on quality of life. Impact on health-related quality of life is optimized when both skin and joint manifestations are effectively treated. The identification of key cytokines involved in disease pathogenesis has led to the development of several therapeutic options for psoriatic disease. When selecting a therapy, it is important to consider disease severity, psoriasis disease subtypes or domains of psoriatic arthritis, comorbidities, patient preference for treatment, among other factors. This review summarizes current biologic and small molecule treatment options as well as emerging therapies for moderate-to-severe adult plaque psoriasis and psoriatic arthritis.

Cardiometabolic multimorbidity is common among patients with psoriasis and is associated with poorer outcomes compared to those without comorbidity

BACKGROUND

Associations between cardiometabolic multimorbidity and response to therapy in psoriasis are unknown.

OBJECTIVE

Determine the associations of multimorbidity with response to biologic treatment in psoriasis patients.

METHODS

CorEvitas Psoriasis Registry participants who initiated biologic therapy and had 6-months follow-up were stratified by 0, 1, 2+ comorbidities (diabetes, hypertension, hyperlipidemia). Adjusted odds ratios (95% CIs) were calculated overall and separately by biologic class (TNFi, IL-17i, IL-12/23i + IL-23i), to assess the likelihood of achieving response for the 1 and 2+ groups vs. 0.

RESULTS

Of 2,923 patients, 49.5%, 24.7% and 25.8% reported 0, 1 and 2+ comorbidities, respectively. Overall, likelihood of PASI75 was 18% (OR =0.82; 95%CI: 0.67, 1.00) and 23% (OR =0.77; 95%CI: 0.63, 0.96) lower in those with 1 and 2+ comorbidities, respectively, vs. 0. In those who initiated IL-17i, odds of PASI75 and PAS90 were 34% (OR =0.66; 95%CI: 0.48-0.91) and 35% (OR =0.65; 95%CI: 0.47-0.91) lower in the 2+ multimorbidity cohort. No significant associations were found among users of TNFi or IL-12/23i + IL-23i groups in the multimorbidity group.

LIMITATIONS

Patients may not be representative of all psoriasis patients.

CONCLUSION

Multimorbidity in psoriasis may decrease the likelihood of achieving treatment response to biologic therapy and should be considered when discussing treatment expectations with patients.

Comorbid obesity and history of diabetes are independently associated with poorer treatment response to biologics at 6 months: A prospective analysis in Corrona Psoriasis Registry

BACKGROUND

Psoriasis is associated with comorbid systemic metabolic disease.

OBJECTIVE

To assess possible associations of comorbid obesity, history of diabetes, hypertension, and hyperlipidemia with response to biologic treatment at 6 months among patients in CorEvitas' Psoriasis Registry.

METHODS

Participants included 2924 patients initiating biologic therapy (tumour necrosis factor inhibitors [TNFi], interleukin [IL]-17i, IL-12/23i, or IL-23i) with baseline and 6-month follow-up visits available. Logistic regressions resulted in adjusted odd ratios (OR) and 95% confidence intervals (CI) for achievement of response in select outcomes for those with obesity and history of diabetes, hypertension, and hyperlipidemia relative to those without each.

RESULTS

Overall, obesity reduced by 25% to 30% odds of achieving PASI75 (OR, 0.75; 95% CI, 0.64-0.88) and PASI90 (OR, 0.70; 95% CI, 0.59-0.81). History of diabetes reduced odds of achieving PASI75 by 31% (OR, 0.69; 95% CI, 0.56-0.85) and PASI90 by 21% (OR, 0.79; 95% CI, 0.63-0.98). Obesity was associated with lower response to TNFi and IL-17i classes. Independent of obesity, diabetes was associated with poorer outcomes when on IL-17i therapy and hypertension, to a lesser extent, when on the TNFi class. No significant associations were found in the hyperlipidemia group.

LIMITATIONS

The study assessed only short-term effectiveness and small sample sizes limited the power to detect differences.

CONCLUSION

Assessment of comorbid disease burden is important for improved likelihoods of achieving treatment response with biologics.

Body Mass Index Influence for the Personalization of the Monoclonal Antibodies Therapy for Psoriasis

Psoriasis is a chronic inflammatory, autoimmune-mediated disease that affects millions of individuals worldwide. Advances in treatment with biological agents represented by monoclonal antibodies, such as TNF-α inhibitors (TNFI), IL-17A and IL-12/23 antagonists have not only benefited from outstanding clinical efficacy with lower side effects compared to conventional systemic therapy, but also raised the standards towards therapeutic success, fact reflected in the greater Psoriasis Area and Severity Index (PASI) response rates. However, due to their relatively recent introduction in clinical practice, and despite their proven superior efficacy, further research is needed for monitoring the eventual changes in treatment-induced parameters, especially of metabolic origin. In this respect, initial reports stress on one particular comorbidity associated with psoriasis-obesity-which seems to be not only a risk and result of the disease, but also an adverse effect of long-term therapy with some biologics. The consequent drug-induced increase in body mass index (BMI) of patients suffering from psoriasis undergoing biological treatment appears to contribute to the progression of the disease, promote drug discontinuation and reduce overall clinical efficacy of monoclonal antibodies. Therefore, we review herein the impact of body weight (BMI) increase on the biological treatment of psoriasis, to further investigate on its relationship with the disease and aid on the management of treatment schemes that take into account individual characteristics of patients, such as body mass, for a more efficient and personalized therapy approach.

Association between infliximab concentrations and clinical response in psoriasis: a prospective cohort study

BACKGROUND

Infliximab (IFX) trough concentrations (C_min) have been linked to treatment efficacy in psoriatic patients. Inter-individual IFX C_min variability and factors influencing IFX pharmacokinetics could explain differences in treatment response.

OBJECTIVE

To evaluate the association between IFX C_min and clinical outcomes in psoriatic patients.

METHODS

Prospective study of 33 patients with moderate to severe psoriasis receiving IFX at Bellvitge University Hospital, between October 2013 and November 2016. IFX C_min and antibodies toward infliximab (ATI) were measured.

RESULTS

We collected 155 IFX C_min and ATI values (mean age, 46 (14) years; 11 (33.3%) women). Mean IFX C_min was 2.5 (2.4) mg/L and ATIs were detected in six patients, resulting in undetectable IFX C_min. IFX C_min was significantly associated with ATI and body mass index (BMI) (β -2.51, 95% CI -3.56 to -1.4 and β -0.05, 95% CI -0.09 to -0.01). PASI score and PASI 90/100 response were significantly associated with IFX C_min (IRR 0.80, 95% CI 0.70 to 0.92; OR 1.79, 95% CI 1.18 to 2.71 and OR 1.79, 95% CI 1.14 to 2.81).

CONCLUSION

IFX C_min significantly influences PASI 90/100 response rates. IFX C_min wa significantly associated with ATI and BMI. The observed inter-individual variability in IFX C_min supports the need for IFX drug monitoring.

Body weight increment in patients treated with infliximab for plaque psoriasis

BACKGROUND

Psoriasis is frequently associated with overweight and obesity. Anti-TNF-α therapies are effective in the treatment of psoriasis. TNF-α is highly involved in body weight regulation.

OBJECTIVE

Our objective was to evaluate the increase in weight throughout the treatment with infliximab and the association of weight gain with the body mass index (BMI).

METHODS

Thirty-five patients affected with severe plaque psoriasis receiving infliximab were included. A control group consisted of 16 patients affected with severe plaque psoriasis and treated with cyclosporine, methotrexate, or acitretin. Assessment of PASI score, body weight and BMI were performed at a 1 and 3-year follow-up.

RESULTS

We observed a body weight increment of 2.5 ± 4.4 kg (mean ± SD) (i.e. + 3.6% of baseline) and 0.1 ± 5 kg (i.e. + 1.2%) in patients treated with infliximab and the control group, respectively (P = 0.046), after 1 year of treatment. After 3 years of infliximab administration, weight gain was 4.8 ± 5 kg (n = 16) (i.e. + 6%) (P = 0.005). Moreover, as classified by BMI, normal weight patients experienced a 4 ± 3.7 kg weight gain (i.e. + 6%) whereas overweight and obese patients had gained 1.3 ± 4.8 kg (i.e. + 1.2%) (P = 0.039) after 1 year of anti-TNF-α therapy. Percentual changes in body weight were larger in normal weight patients at baseline than in overweight/obese counterparts (P = 0.0149).

CONCLUSION

All patients, including normal weight patients, should receive a dietary intervention.