Biologic Therapeutics in the Treatment of Psoriasis. Part 1: Review

Analytical ultracentrifugation with fluorescence detection system reveals differences in complex formation between recombinant human TNF and different biological TNF antagonists in various environments

A number of studies have attempted to elucidate the binding mechanism between tumor necrosis factor (TNF) and clinically relevant antagonists. None of these studies, however, have been conducted as close as possible to physiologic conditions, and so the relationship between the size distribution of TNF-antagonist complexes and the antagonists' biological activity or adverse effects remains elusive. Here, we characterized the binding stoichiometry and sizes of soluble TNF-antagonist complexes for adalimumab, infliximab, and etanercept that were formed in human serum and in phosphate-buffered saline (PBS). Fluorescence-detected sedimentation velocity analytical ultracentrifugation analyses revealed that adalimumab and infliximab formed a range of complexes with TNF, with the major complexes consisting of 3 molcules of the respective antagonist and one or 2 molcules of TNF. Considerably greater amounts of high-molecular-weight complexes were detected for infliximab in human serum. The emergence of peaks with higher sedimentation coefficients than the adalimumab monomer as a function of added human serum albumin (HSA) concentration in PBS suggested weak reversible interactions between HSA and immunoglobulins. Etanerept exclusively formed 1:1 complexes with TNF in PBS, and a small amount of complexes with higher stoichiometry was detected in human serum. Consistent with these biophysical characterizations, a reporter assay showed that adalimumab and infliximab, but not etanercept, exerted FcγRIIa- and FcγRIIIa-mediated cell signaling in the presence of TNF and that infliximab exhibited higher potency than adalimumab. This study shows that assessing distribution profiles in serum will contribute to a more comprehensive understanding of the in vivo behavior of therapeutic proteins.

Infliximab treatment of psoriasis in supervised infusion centers: case management experience

Psoriasis is a systemic chronic inflammatory disease that affects 1-3% of the world's population. Knowledge of the pathogenesis of psoriasis, particularly in the understanding of the role of T cells and tumor necrosis factor α (TNFα), and advances in immunology have led to the development of biological agents, which, due to their great effectiveness, speed of response and good tolerability, have revolutionized patient management. One of these is infliximab, a human chimeric immunoglobulin G1 monoclonal antibody composed of human antibody constant regions and murine variable regions that was developed specifically to target TNFα. The six cases presented in this series highlight the feasibility, efficacy and safety of infliximab for psoriasis when administered in a variety of patients in several infusion centers across Spain. All six patients showed improvement in their psoriasis after the initiation of infliximab and no significant tolerability issues or injection site reactions were reported, despite the presence of several comorbid conditions or patient characteristics that traditionally reduce the efficacy of psoriasis treatments. This suggests that while the management of psoriasis patients with comorbid conditions and various unfavorable prognostic characteristics requires a multidisciplinary approach to ensure the patient obtains the best therapeutic response, infliximab is an effective and well tolerated treatment in these patients.

Off-label uses of anti-TNF therapy in three frequent disorders: Behçet's disease, sarcoidosis, and noninfectious uveitis

Tumoral necrosis factor α plays a central role in both the inflammatory response and that of the immune system. Thus, its blockade with the so-called anti-TNF agents (infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab) has turned into the most important tool in the management of a variety of disorders, such as rheumatoid arthritis, spondyloarthropatties, inflammatory bowel disease, and psoriasis. Nonetheless, theoretically, some other autoimmune disorders may benefit from these agents. Our aim is to review these off-label uses of anti-TNF blockers in three common conditions: Behçet's disease, sarcoidosis, and noninfectious uveitis. Due to the insufficient number of adequate clinical trials and consequently to their lower prevalence compared to other immune disorders, this review is mainly based on case reports and case series.

Prevalence and management of panic attacks during infliximab infusion in psoriatic patients

BACKGROUND

Psoriasis is a chronic, inflammatory skin disease associated with anxiety and depression. Infliximab (IFX) is a human/mouse chimeric anti-TNF-α antibody effective in the treatment of psoriasis.

OBJECTIVE

The aim of this study was to evaluate the prevalence of panic disorders in psoriatic patients during IFX infusions.

METHODS

A retrospective study was performed on patients affected with psoriasis who were treated with IFX from 2002 to 2011 at a single center. Panic disorders were defined using the clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. A population of dermatological patients under treatment with IVG, rituximab, apheresis, intravenous corticosteroids and antibiotics was considered as the control group.

RESULTS

A total of 141 patients were evaluated. Of these, 6 (4.25%) experienced panic attacks during the infusion; 16 (11.3%) had a medical history of panic attack and of those 5/16 (31%) experienced panic attacks during IFX infusion. In the control group panic attacks were not recorded.

CONCLUSION

We describe 6 cases of patients in whom panic attacks were triggered by IFX infusion. Premedication with oral benzodiazepine and a slow rate of infusion is recommended.

Clastogenic plasma factors in psoriasis--comparison of phototherapy and anti-TNF-α treatments

As previously described, Psoralen plus UVA (PUVA) therapy induces chromosome damage in psoriatic patients. This study evaluates whether these effects are transitory or persistent. In addition, we studied these effects after narrowband UVB (nUVB) and anti-tumor necrosis factor (TNF)-α treatments. Among 40 responder patients, 10 received PUVA, 10 nUVB, 10 Infliximab and 10 Etanercept. Disease activity was determined with Psoriasis Area and Severity Index. Chromosomal breakage was evaluated by the clastogenic factor (CF) test. Potential clastogenic agents, malondialdehyde (MDA) and TNF-α were measured. Before treatment, the plasma-adjusted clastogenic scores (ACS) of patients were increased. During treatment, a further increase in ACS was observed in both phototherapy groups. Chromosome damage persisted for PUVA patients at week 32, while it diminished after nUVB to ACS values lower than before treatment. MDA and TNF-α values were also increased at baseline. MDA decreased during treatment in all groups, but without reaching normal levels. Plasma TNF-α remained unchanged in PUVA and nUVB but decreased in both anti-TNF-α treatment groups. Psoriasis is accompanied by CF-induced chromosomal breakage that increases during PUVA and nUVB treatments. Plasma clastogenic activity persisted in the follow-up after PUVA, while after nUVB ACS returned to values even lower than baseline. Clastogenic activity during the induction phase with anti-TNF-α remained unchanged.

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.

The safety profile and sustained remission associated with response to multiple courses of intramuscular alefacept for treatment of chronic plaque psoriasis

BACKGROUND

Safety and efficacy of up to 3 courses of alefacept intramuscular (IM) in the treatment of chronic plaque psoriasis have been demonstrated in earlier trials.

OBJECTIVE

We sought to determine the safety and efficacy of up to 5 courses of alefacept IM in treating plaque psoriasis.

METHODS

A standard treatment course was defined as 15 mg of alefacept IM once weekly for 12 weeks, followed by 12 weeks of treatment-free observation. Patients with chronic plaque psoriasis, who had previously received alefacept IM, received up to 3 additional courses (A, B, and C). Efficacy was evaluated by Physician Global Assessment.

RESULTS

Safety profiles were similar to those for a single course of treatment. There were no cumulative adverse effects. At 2 weeks postdosing, 16%, 22%, and 19% of patients were rated clear or almost clear by Physician Global Assessment in courses A, B, and C, respectively, with 35%, 42%, and 42% achieving this response at any time during these courses. Patients who achieved clear or almost clear at 2 weeks postdosing remained so for a median duration of 214 and 126 days after courses A and B, respectively.

LIMITATIONS

This was an extension study and therefore contained no control group.

CONCLUSIONS

Up to 5 courses of alefacept IM may provide extended treatment-free, symptom-free periods in responders while maintaining the safety profile.

Biologics in the Treatment of Psoriasis: Clinical and Economic Overview

Background:

The use of biologic medications for psoriasis is a recent therapeutic advance.

Objective:

To review clinical and economic data for biologic therapies in the treatment of chronic plaque psoriasis.

Methods:

Published meta-analyses and additional literature review identified randomized controlled trials. Analyses included the number needed to treat (NNT), the cost in Canadian dollars for the first year of treatment per the Canadian product monograph, and the estimated cost per responder achieving a 75% reduction in Psoriasis Area and Severity Index score (PASI 75).

Results:

Pooled NNTs were 1.3 (infliximab), 1.5 (ustekinumab 90 mg), 1.6 (adalimumab and ustekinumab 45 mg), 2.3 (etanercept), 4.1 (efalizumab), and 5.6 (alefacept). The annual treatment cost per patient was $19,825 to $37,600. The cost per patient achieving a PASI 75 response at 12 weeks ranged from $8,330 (adalimumab) to $71,371 (alefacept).

Conclusion:

This analysis suggests favorable cost and benefits of biologic psoriasis therapies, particularly adalimumab, infliximab, and ustekinumab.

[Efficacy of TNF-alpha antagonists for plaque-type psoriasis: a systematic review and graphical presentation]

BACKGROUND

Numerous studies investigating the efficacy of TNF-alpha antagonists in moderate-to-severe plaque-type psoriasis have been published. We present a graphic synthesis of efficacy data based on a systematic review of the published studies.

METHODS

The Medline, Embase and Cochrane Library bibliographic databases were searched for studies based on the following selection criteria: 1. Original studies, 2. Using infliximab, etanercept or adalimumab as the sole systemic treatment for plaque-type cutaneous psoriasis, 3. Minimum follow-up of 10 weeks, 4. Use of the PASI75 index (improvement of at least 75% from baseline PASI score) as an endpoint. Twenty-one articles were selected and PASI75 scores and corresponding 95% confidence intervals were calculated at three, six and 12 months.

RESULTS

At M3, success rates were about 80% with infliximab and adalimumab once-weekly, around 50% with etanercept 50mg twice-weekly and adalimumab fortnightly; and 30% with etanercept 25mg twice-weekly. Maintenance regimens after three months ensured success rates above 50% with all three treatments, although the long-term results were based on fewer studies.

CONCLUSION

Our graphic synthesis and tolerance data for the three drugs should guide clinicians in their therapeutic choices in moderate-to-severe plaque-type psoriasis. Additional studies with better reporting of loss to follow-up are needed to better assess the long-term efficacy of these drugs.

Homeopathic treatment of patients with psoriasis--a prospective observational study with 2 years follow-up

Design Prospective multicentre observational study. Objective To evaluate details and effects of homeopathic treatment in patients with psoriasis in usual medical care. Methods Primary care patients were evaluated over 2 years using standardized questionnaires, recording diagnoses and complaints severity, health-related quality of life (QoL), medical history, consultations, all treatments, and use of other health services. Results Forty-five physicians treated 82 adults, 51.2% women, aged 41.6 +/- 12.2 (mean +/- SD) years. Patients had psoriasis for 14.7 +/- 11.9 years; 96.3% had been treated before. Initial case taking took 127 +/- 47 min. The 7.4 +/- 7.4 subsequent consultations (duration: 19.4 +/- 10.5 min) cumulated to 169.0 +/- 138.8 min. Patients received 6.0 +/- 4.9 homeopathic prescriptions. Diagnoses and complaints severity improved markedly with large effect sizes (Cohen's d= 1.02-2.09). In addition, QoL improved (SF-36 physical component score d = 0.26, mental component score d = 0.49), while conventional treatment and health service use were considerably reduced. Conclusions Under classical homeopathic treatment, patients with psoriasis improved in symptoms and QoL.