Fulfilling an Unmet Need in 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.

Synthesis and Biological Evaluation of Thalidomide Derivatives as Potential Anti-Psoriasis Agents

Several thalidomide derivatives were synthesized and evaluated for their anti-inflammatory activity. Introduction of the benzyl group to the parent thalidomide is unfavorable in which 2-(1-benzyl-2,6-dioxopiperidin-3-yl)isoindoline-1,3-dione (4a) was inactivated. However, the inhibitory activities on TNF-α and IL-6 expression in HaCaT cells were improved by the substitution of a chloro- or methoxy- group at the phenyl position of 4a. The IL-6 inhibitory activity decreased in an order of 5c (69.44%) > 4c (48.73%) > 6c (3.19%) indicating the 3-substituted derivative is more active than the 4-substituted counterpart, which in turn is more active than the 2-substituted counterpart. Among them, 2-[1-(3-chlorobenzyl)-2,6-dioxopiperidin-3-yl]isoindoline-1,3-dione (5c) was found to inhibit TNF-α and IL-6 expression in HaCaT cells with a higher potency than thalidomide and no significant cell cytotoxicity was detected at 10 μM. In psoriasis, Compound 5c reduced IL-6, IL-8, IL-1β and IL-24 in imiquimod-stimulated models. Our results indicated that compound 5c is a potential lead of novel anti-psoriasis agents. Structural optimization of compound 5c and its in vivo assay are ongoing.

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.

Drug survival of fumaric acid esters for psoriasis: a retrospective study

BACKGROUND

Fumaric acid esters (FAEs) have been used for over 30 years in the management of psoriasis.

OBJECTIVES

To determine drug survival of FAEs in patients with psoriasis, treatment-limiting adverse drug events and the range of effective drug doses.

METHODS

A retrospective, single-centre study assessing all patients commenced on FAEs between October 2003 and July 2012. Demographic data, length of treatment, reasons for discontinuation of FAEs, side-effects and range of doses were recorded.

RESULTS

Two hundred and forty-nine patients [160 (64%) male] were included. The mean age at which FAEs were commenced was 44·5 years (range 17-82 years). The mean length of treatment was 28 months (range 1 week to 106 months). In patients who were commenced on FAEs ≥ 4 years before inclusion in this study, the 4-year drug survival was 60% (64/107). FAEs were discontinued in 146/249 patients (59%); this was due to lack of efficacy in 59/146 (40%) and gastrointestinal upset in 39/146 (27%). A very low dose of FAEs (< 240 mg daily) was successful in maintaining control of psoriasis in 26 (10%) patients. The mean treatment duration of these patients was 64 months (range 32-106 months).

CONCLUSIONS

Fumaric acid esters have a 4-year drug survival rate of 60%, which compares favourably with reported 4-year survival rates of 40% for etanercept and adalimumab and 70% for infliximab. Longer drug survival is more likely in the significant subgroup of patients in whom a very low dose of FAEs is sufficient to control disease. The reasons for this are unclear.

Ustekinumab: a review of its use in the management of moderate to severe plaque psoriasis

Ustekinumab (Stelara™) is a human monoclonal antibody that binds to the p40 subunit common to both interleukin (IL)-12 and IL-23. It is indicated in the US for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. In the EU, it is indicated for those who failed to respond to, have a contraindication to or are intolerant of other systemic therapies or phototherapy. This article reviews the efficacy and tolerability of ustekinumab in patients with moderate to severe plaque psoriasis, as well as summarizing its pharmacological properties. Ustekinumab attenuates the immune cell activation properties of IL-12 and IL-23. It interrupts the abnormal activation of signalling and cytokine cascades that underlie the pathology of psoriasis by reducing the expression of IL-12- and IL-23-induced cell surface markers that mediate skin homing, activation and cytokine release. In well designed, randomized clinical trials, regimens of subcutaneous ustekinumab 45 or 90 mg provided a rapid and durable improvement in psoriasis area severity index (PASI) scores for patients with moderate to severe plaque psoriasis. A significantly greater proportion of patients receiving ustekinuman 45 or 90 mg compared with those receiving placebo achieved a ≥75% improvement from baseline in PASI score following 12 weeks' treatment (primary endpoint). Improvements in PASI scores were evident following 2 weeks' treatment with ustekinumab and were sustained for up to 3 years. Treatment with ustekinumab 45 or 90 mg also improved health-related quality-of-life scores from baseline. Following 12 weeks' treatment, ustekinumab 45 or 90 mg was more effective than etanercept 50 mg twice weekly in providing symptomatic relief for patients with moderate to severe plaque psoriasis. Furthermore, ustekinumab treatment provided effective symptomatic improvement for almost half of the patients who showed no response to 12 weeks' treatment with etanercept. More limited data indicate that ustekinumab also improves the symptoms of arthritis in patients with plaque psoriasis and psoriatic arthritis. Subcutaneous ustekinumab was generally well tolerated in clinical trials; most adverse events were mild in intensity and did not require dosage adjustment. A pooled analysis of clinical trial data indicated no specific patterns of infection for recipients of ustekinumab and that infection rates remained stable following cumulative exposure to the agent. In conclusion, subcutaneous ustekinumab provides an effective and well tolerated alternative for the symptomatic treatment of patients with moderate to severe plaque psoriasis.

Integrated safety analysis: short- and long-term safety profiles of etanercept in patients with psoriasis

BACKGROUND

Multiple trials demonstrate the tolerability and safety of etanercept. However, there are limited data on etanercept tolerability in large populations of patients with psoriasis or with extended therapy.

OBJECTIVES

We sought to determine whether there is an increased safety risk associated with higher etanercept doses or with extended exposure in patients with psoriasis.

METHODS

Integrated adverse event (AE) data from etanercept psoriasis trials were used to evaluate short-term (up to 12 weeks from controlled studies) and long-term (up to 144 weeks from uncontrolled extension studies) safety of etanercept (25 mg once weekly to 50 mg twice weekly). Long-term data were stratified by treatment regimens. Rates of noninfectious and infectious AE and standardized incidence ratios for malignancies were determined.

RESULTS

In short-term analyses, rates of noninfectious and infectious AE and serious noninfectious and infectious AE were comparable between placebo and etanercept groups. In both short- and long-term analyses, there were no dose-related increases in these events. Cumulative event rates for serious infections were not significantly different across dose groups and over time. The standardized incidence ratios for malignancies excluding nonmelanoma skin cancers did not achieve statistical significance. There was no increase in overall malignancies with etanercept therapy compared with the psoriasis population. Lymphoma (n = 2 patients), demyelination (n = 2), congestive heart failure (n = 7), and opportunistic infection (n = 1) were rare.

LIMITATIONS

Study limitations include the rarity of some events and the resultant broad 95% confidence intervals.

CONCLUSIONS

In this integrated analysis, etanercept was well tolerated, and there were no signs of dose-related or cumulative toxicity over time.

Infliximab for the treatment of plaque psoriasis

Infliximab is a monoclonal antibody that targets tumor necrosis factor-α (TNFα). It is used in the treatment of a number of inflammatory disorders including severe plaque psoriasis. TNFα is thought to have a major role in psoriasis by promoting an inflammatory infiltrate into the skin and inducing keratinocyte proliferation and preventing keratinocyte apoptosis, which directly contributes to the characteristic plaque skin lesions. Based on four randomized, placebo-controlled, double-blind clinical trials and nine open-label uncontrolled trials of the use of infliximab in plaque psoriasis, it was found that infliximab is a highly efficacious, rapid, sustainable, and relatively safe therapy. Yet as with any biologic, caution is recommended in its use as infusion reactions, lupus-like syndromes, infections, malignancies including lymphomas, as well as other rare events have been reported.

Psoriasis responds to intralesional injections of alefacept and may predict systemic response to intramuscular alefacept: interim results of a single-arm, open-label study

BACKGROUND

Alefacept is a remittive treatment for generalized psoriasis but is rarely used due to its erratic efficacy.

OBJECTIVE

To determine if psoriasis plaques will respond to intralesional alefacept and if this predicts a systemic response to intramuscular (IM) alefacept.

METHODS

We describe a 25-week, single-center, open-label study. Patients received weekly intralesional alefacept of increasing concentrations into target plaques for 3 weeks followed by IM injections for 12 weeks and concluded with an observation period of 9 weeks. The psoriasis area and severity index (PASI) was used to assess the efficacy of IM alefacept.

RESULTS

Interim results are reported for the first seven patients enrolled. Two patients responded intralesionally to the most dilute 1:100 concentration of alefacept to sterile water and achieved a 59% and 100% improvement in PASI. Five patients did not respond intralesionally to the most dilute form of alefacept and none achieved PASI 75. Two of these five patients did not respond to any concentration and achieved a 26% and 38% improvement in PASI. Limitations to this study include a small sample size and being non-placebo-controlled.

CONCLUSION

Alefacept is effective intralesionally and may predict a systemic response - challenging the concept that biologics must work systemically.

Etanercept: an evolving role in psoriasis and psoriatic arthritis

Tumor necrosis factor alpha (TNFalpha) plays a key pathophysiological role in psoriasis and psoriatic arthritis (PsA). Recent interest has thus focused on the clinical potential of TNFalpha antagonists (e.g. etanercept) in these settings. In psoriasis, several large pooled analyses and well-designed clinical trials documented the significant clinical efficacy and generally favorable tolerability of etanercept for up to 96 weeks. Similarly, in PsA, a large phase III trial showed that, etanercept significantly reduced arthritic symptoms and inhibited radiographic disease progression; sustained clinical benefit was again evident for up to 2 years. Etanercept is at the forefront of psoriatic disease management, and continued evolution and evaluation of the compound - for example, in detailed comparative studies and economic analyses - is likely to confirm a key role for etanercept in the treatment of psoriasis and PsA.

Immune mechanisms of psoriasis. New strategies of biotherapy

Psoriasis is a chronic skin disease - according to numerous studies, about 2% of the population suffer from it. Psoriasis degrades the life quality, and such concomitant pathologies as metabolic disorders, cardiovascular diseases and depression shorten the life expectancy of psoriasis patients. Substantial progress has been achieved today in understanding the mechanisms of the disease, searching for new treatment techniques and standardizing the disease severity According to the recent studies, psoriasis belongs to immune-dependent diseases with genetic predisposition to its development. Dendritic cells and T lymphocytes play an important part in psoriasis development. Their interaction launches a number of mechanisms ultimately leading to the inflammatory process development and formation of psoriatic skin affections. Such cytokines as IL-12, IL-23, IFN-y and TNF-a secreted by immunocompetent cells serve as mediators during such processes. An advanced therapeutic approach to the treatment of psoriasis means creating pathogenetically important cytokine specific monoclonal antibodies and placing them into the body Today there are drugs successfully blocking the development of psoriatic skin affections by means of specific binding of IL-12, IL-23 and TNF-a cytokines. Drugs called ustekinumab and ABT-874 confirmed their therapeutic activity with regard to psoriasis at Phases 2 and 3 of clinical trials. In the course of further trials, ustekinumab also demonstrated a safety profile comparable to that of placebo.

Long-term efalizumab therapy for patients with moderate-to-severe, chronic plaque psoriasis: results from an Australian expanded access program

BACKGROUND

Psoriasis is a chronic skin disease that can impact heavily on a patient's well-being. Efalizumab, a unique, targeted, biological therapy, has demonstrated efficacy in treating moderate-to-severe, chronic plaque psoriasis with <or=36 months of continuous therapy. The objective of this Extended Access Program (EAP) was to evaluate further the benefit of efalizumab as long-term therapy in a real-world clinical setting.

METHODS

After an initial conditioning dose of efalizumab (0.7 mg/kg subcutaneously), a weekly dose of efalizumab (1.0 mg/kg) was administered for <or=21 months. Patients with reduced Psoriasis Area and Severity Index (PASI) scores (>or=50%, or a score <or=8) at month 3 entered the long-term maintenance treatment period.

RESULTS

In total, 101 patients (>18 years) with severe plaque psoriasis enrolled on the EAP, of these 93 (92.1%) met all the inclusion criteria. After 3 months of treatment, 84/101 (83.2%) patients had evaluable data and entered the maintenance period. After 3 months, 57/84 (67.9%) patients had achieved PASI-50. Using an intent-to-treat analysis, after 21 months of treatment, PASI-75 and PASI-50 were achieved by 43/101 (42.6%) and 69/101 (68.3%) of patients, respectively. Efalizumab was generally well tolerated during the 21 months of continuous therapy.

CONCLUSION

Efalizumab, 1.0 mg/kg/week, is effective and well tolerated in a 'real world' clinical setting, providing enduring reduction of psoriasis symptoms for up to 21 months.

Psoriasis and risk of incident cancer: an inception cohort study with a nested case-control analysis

Psoriasis has been associated with lymphohematopoietic and solid cancers; however, reports have been inconsistent. Cancer incidence was compared between psoriasis and psoriasis-free patients, and the roles of psoriasis duration and treatment were explored in this observational study using the UK General Practice Research Database. Among 67,761 patients, 1,703 patients had incident cancer; of whom 54% had a history of psoriasis. Incidence rate ratios for lymphohematopoietic and pancreatic cancers were 1.81 (95% confidence interval (CI) 1.35-2.42) and 2.20 (95% CI 1.18-4.09), respectively. In a nested case-control analysis, adjusted odds ratios (ORs) for cancer overall were 1.50 (95% CI 1.30-1.74) for psoriasis of >or=4 years duration and 1.53 (95% CI 0.97-2.43) for patients receiving systemic treatment (marker of disease severity). Lymphohematopoietic malignancy risk was highest in patients with systemic treatment. The OR for patients without systemic treatment was 1.59 (95% CI 1.01-2.50) for psoriasis of <2 years and 2.12 (95% CI 1.45-3.10) for that of >or=2 years duration. Risks of bladder/kidney and colorectal cancers were increased with longer-duration psoriasis. Psoriasis patients may have an increased overall risk of incident cancer (mainly lymphohematopoietic and pancreatic). Longer-term psoriasis and more severe disease may increase the risk of some cancers. These observations need further confirmation, particularly because of the potential of findings by chance in observational studies with subgroup analyses.

Efalizumab in the treatment of psoriasis: when comorbidity is an issue

Psoriasis is a common dermatosis affecting the skin, mucosal surfaces, and cutaneous adnexa, and joints and bones can be involved at some degree in the clinical features of the disease, configuring psoriatic arthritis. Moderate to severe psoriasis has a high impact on quality of life and requires an integrated and long-term treatment schedule. However, management of psoriasis in patients affected by other systemic diseases can be challenging because of the possible side effects or contraindications of various treatments in accordance with patients' medical history. In recent times, the therapeutical approaches have changed a lot, thanks to biologicals. The current authors present some cases of psoriatic patients with comorbidities successfully treated with efalizumab, an anti-T lymphocyte biological.

Discovery and structure-activity study of a novel benzoxaborole anti-inflammatory agent (AN2728) for the potential topical treatment of psoriasis and atopic dermatitis

A series of phenoxy benzoxaboroles were synthesized and screened for their inhibitory activity against PDE4 and cytokine release. 5-(4-Cyanophenoxy)-2,3-dihydro-1-hydroxy-2,1-benzoxaborole (AN2728) showed potent activity both in vitro and in vivo. This compound is now in clinical development for the topical treatment of psoriasis and being pursued for the topical treatment of atopic dermatitis.

Slt2 (Mpk1) MAP kinase is involved in the response of Saccharomyces cerevisiae to 8-methoxypsoralen plus UVA

The bifunctional furocoumarin 8-methoxypsoralen (8-MOP) is a well established drug in the photochemotherapy of psoriasis and other skin diseases. In eukaryotic cells, this compound intercalates into DNA and undergoes photocycloaddition with pyrimidines to form monoadducts and interstrand crosslinks initiating a cascade of events leading to cytotoxic, mutagenic and carcinogenic responses. In yeast cells, exposure to 8-MOP plus UVA induces transcription of a large set of genes, and cellular reaction is different from an overall DNA damage response and specific to 8-MOP/UVA [M. Dardalhon, W. Lin, A. Nicolas, D. Averbeck, Specific transcriptional responses induced by 8-methoxypsoralen and UVA in yeast, FEMS Yeast Res. 7 (2007) 866-878]. To further define the relationship between induced genes and genotoxic consequences after 8-MOP/UVA treatment, the survival responses of mutants deleted for genes that are specifically induced by 8-MOP plus UVA were analysed in terms of survival. Six mutants deleted for RAD51, RAD54, DUN1, DIN7, already known to be implicated in DNA damage responses, and for SLT2/MPK1 and PDE2 involved in cell wall stress responses, were found sensitive to 8-MOP plus UVA treatment. Further characterization of slt2 mutant provides evidence for the existence of an 8-MOP/UVA response in yeast in which the yeast Slt2 MAPK pathway is implicated. Activation by 8-MOP plus UVA of this MAP kinase previously observed at the transcriptional level is now confirmed at the protein level. In addition to sensitivity to 8-MOP/UVA, yeast cells lacking SLT2 show reduced survival after 3-carbethoxypsoralen plus UVA and 1,6-dioxapyrene plus UVA. Osmotic support could suppress the sensitivities to these genotoxic agents, suggesting that these sensitivities are related to cell integrity defects and/or cell wall defects.

Adalimumab: in plaque psoriasis

Adalimumab is a recombinant, human, IgG1 monoclonal antibody specific for tumor necrosis factor. The clinical efficacy and safety of adalimumab (40 mg administered subcutaneously every other week) in patients with moderate-to-severe chronic plaque psoriasis have been demonstrated in several randomized, double-blind clinical trials, including the pivotal trials REVEAL (n = 1212) and CHAMPION (n = 271). Based on these trials, adalimumab was significantly more effective than placebo and methotrexate at relieving the signs and symptoms of psoriasis after 16 weeks of treatment, as assessed by the percentage of patients achieving a 75% improvement from baseline in Psoriasis Area and Severity Index. Based on open-label extension studies of up to 2 years' duration, the efficacy of adalimumab was sustained over the long term. Of patients who had responded to 33 weeks of treatment with adalimumab in REVEAL, patients randomized to remain on adalimumab for an additional 19 weeks of treatment were significantly less likely to experience loss of an adequate response than patients who were transferred to placebo. Compared with placebo or methotrexate, adalimumab was associated with significantly greater improvements in dermatology-specific and general measures of health-related quality of life in patients with plaque psoriasis. Adalimumab was generally well tolerated in trials in patients with plaque psoriasis, and the adverse-event profile was similar to that associated with its use in rheumatoid arthritis.

Efalizumab: a review of its use in the management of chronic moderate-to-severe plaque psoriasis

Efalizumab (Raptiva) is a recombinant, humanized, monoclonal antibody that targets CD11a, the alpha-subunit of the heterodimeric lymphocyte surface protein lymphocyte function-associated antigen-1 (LFA-1). It is approved for the treatment of adult patients (aged > or = 18 years) with chronic moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy (in the US), or who have failed to respond to, have a contraindication to, or are intolerant of, other systemic therapies, including cyclosporine (ciclosporin), methotrexate, and psoralen plus UVA photochemotherapy (in the EU). Weekly subcutaneous injections of efalizumab are effective and generally well tolerated in the treatment of adults with chronic moderate-to-severe plaque psoriasis, including high-need individuals (i.e. those for whom at least two currently available systemic therapies are unsuitable due to lack of efficacy, intolerance, or contraindication), and patients with difficult-to-treat forms of the disease affecting the scalp, hands/feet, or nails. Clinical improvements are maintained, with no evidence of cumulative or end-organ toxicity, during continuous administration of efalizumab for up to 3 years; 4-, 5-, and 7-year safety data are being collected. The therapeutic profile of efalizumab cannot be directly compared with that of other antipsoriasis agents because of a lack of head-to-head comparative studies. Nonetheless, a considerable body of data indicates that efalizumab is an appropriate alternative to other biologic or nonbiologic therapies for the treatment of chronic moderate-to-severe plaque psoriasis that, additionally, offers the potential convenience of self-injection at home.

Therapeutic potential of selectin antagonists in psoriasis

Psoriasis is a systemic chronic inflammatory disorder. One of the major characteristics is an excess of infiltration of inflammatory cells, mainly lymphocytes, into the skin. Because the adhesion family of selectins is suggested to play a relevant role in this process, selectins have emerged as an interesting target for drug discovery and development in psoriasis. Different strategies targeting selectins have been described. This review discusses these approaches and summarises the current development of selectin antagonists for the treatment of psoriasis. An expert opinion will give the authors' personal opinion about selectin antagonism in psoriasis and which approach might be preferable.

Efficacy and safety of etanercept in psoriasis/psoriatic arthritis: an updated review

The introduction in recent years of biologic medicines has greatly changed the treatment of psoriasis and psoriatic arthropathy (PsA). These drugs have been effective in the treatment of these chronic, physically weakening disorders, offering good efficacy and a safety profile that differs from those of all other systemic therapies and medications available to date. Different studies have assessed the efficacy and safety of etanercept in the treatment of psoriasis and PsA. Etanercept therapy for up to 144 weeks in psoriasis has shown maintenance of efficacy over time, recapture of initial clinical responses in patients who interrupted their etanercept therapy and were re-treated, an increased percentage of clinical responses in medium-dose non-responding patients who switched to higher dosages, good responses on quality-of-life tests, and an adverse event-adjusted rate similar to placebo. In PsA, etanercept therapy for up to 96 weeks was associated with inhibition of radiologic progression of the disease in addition to maintenance of efficacy over time and good responses on quality-of-life tests. In studies of patients with psoriasis, the adverse effects of etanercept were mostly mild, did not require discontinuation of treatment, and were not associated with cumulative toxicity over time. However, safety concerns about etanercept therapy are well known, and include injection-site reactions, infections, congestive heart failure, demyelinating diseases, lupus-like syndromes, and neoplasms. There are no data about any new safety concerns when etanercept is combined with systemic traditional therapies, although use of this therapy has been reported in only a small number of patients to date.Non-neutralizing anti-etanercept antibodies are not related to a decreased response to therapy and neutralizing antibodies have not been described to date. Treatment of patients infected with hepatitis C virus or HIV does not increase viral load in either case, affect liver function tests, or increase the risk of infections. To date, the available data suggest that use of etanercept during pregnancy or in breast-feeding women should be avoided. Children and the elderly may be treated with similar efficacy and safety profiles as have been observed in adults. Non-live vaccines can be administered to patients taking etanercept. Because of its long-term efficacy and safety, etanercept is likely to become a treatment option for consideration in the long-term management of patients with psoriasis and PsA.

A phase 1, double-blind, placebo-controlled study evaluating single subcutaneous administrations of a human interleukin-12/23 monoclonal antibody in subjects with plaque psoriasis

OBJECTIVE

To evaluate safety, pharmacokinetics, pharmacodynamics, and clinical response of single subcutaneous (s.c.) administrations of a human monoclonal antibody against the p40 subunit of IL-12/23 (IL-12/23 mAb) in subjects with moderate-to-severe psoriasis.

METHODS

Twenty-one subjects were enrolled sequentially into 4 dose cohorts (0.27, 0.675, 1.35, and 2.7 mg/kg) and randomized to IL-12/23 mAb or placebo in a 4:1 ratio. Laboratory/clinical parameters and pharmacokinetics were evaluated through Week 24; mRNA cytokine expression was measured in psoriatic plaques at Week 1.

RESULTS

Mostly mild adverse events and no serious adverse events were reported. The pharmacokinetics (Cmax and AUC) of IL-12/23 mAb increased in an approximately dose-proportional manner. Of the 17 subjects who received IL-12/23 mAb, 13 achieved PASI 75 (compared with no placebo subjects). mRNA expression of IL-8, IL-18, and IFN-gamma in psoriatic plaques decreased in subjects with sustained Psoriasis Area and Severity Index (PASI) improvement.

LIMITATIONS

Interpretation of results is limited due to the small sample size in each dose cohort.

CONCLUSION

A single s.c. administration of IL-12/23 mAb was well tolerated and showed clinical response in subjects with moderate-to-severe psoriasis.

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.