The Impact of Body Mass Index Upon the Efficacy of Adalimumab in Hidradenitis Suppurativa

Biologics for Hidradenitis suppurativa: evolution of the treatment paradigm

INTRODUCTION

Hidradenitis suppurativa (HS) is an autoinflammatory skin disease with a high unmet need for effective medical management. Clinically, it is characterized by inflammatory nodules that may progress into abscesses, draining tunnels and extensive scarring, mainly affecting apocrine gland-bearing areas.

AREAS COVERED

Treatment options include topical and systemic medications and a variety of surgical procedures. The anti-TNF-α antibody adalimumab and the anti-IL-17 secukinumab are the only two approved biologics for HS, showing moderate efficacy. HS research is a rapidly growing field, with a wide range of agents leveraging distinct mechanisms of action currently under development. Drugs targeting the IL-17 and Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways are the most advanced in both ongoing and completed Phase 3 studies, promising deeper levels of response. Use of other, off-label biologics is also discussed.

EXPERT OPINION

A therapeutic algorithm is proposed based on comorbidities and existing evidence. Patient-tailored combinations between biologics and other biologics or small molecules will hopefully allow clinicians to target most events in HS pathophysiology in a complementary way while obtaining a meaningful effect on their devastating manifestations.

Expert consensus on priority research gaps in dietary and lifestyle factors in hidradenitis suppurativa: a Delphi consensus study

Hidradenitis suppurativa (HS) is a debilitating systemic inflammatory disease with limited treatment options. Although management through dietary and lifestyle changes is a primary interest of the HS patient community, there is lack of consensus regarding recommendations due to the paucity of evidence. To establish the priority research gaps on this topic, we performed and moderated a Delphi consensus study by integrating expert opinions and the relevant literature. Based on a literature review, research questions on dietary and lifestyle interventions in HS were constructed. HS dietary and lifestyle research questions were sent to an expert panel, consisting of 22 international members, including dermatologists, dietitians, pharmacists, and endocrinologists. Voting on the research questions was conducted using a modified Delphi technique. The primary outcome measure was whether participants could reach consensus on the priority of each research question in the HS dietary and lifestyle factors. After three rounds of surveys investigating the relationships between HS and various diet and lifestyle factors, "BMI", "Obesity", and "Smoking", reached consensus as high priority research questions. Low research priorities per consensus included "effects of iron supplements", "effects of magnesium supplements", "alcohol consumption" and "limiting Brewer's yeast intake. Smoking and obesity were identified as important research questions, concurrent to the literature indicating their association with more significant impact on disease activity. By shedding light on high priority research questions, our study provides a roadmap for further research on dietary and lifestyle modifications in HS and will help determine evidence-based lifestyle and dietary recommendations for patients with HS.

Obesity and hidradenitis suppurativa: targeting meta-inflammation for therapeutic gain

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition of the pilosebaceous unit. The typical patient with HS is characterized as someone with obesity, who smokes and who has nodules, abscesses and/or draining tunnels predominantly distributed in intertriginous skin. It has been established that lifestyle and genetic factors are the main pathophysiological drivers of HS. In this critical review, we explore the interrelatedness of meta-inflammation, obesity and HS and discuss if and how this relationship may be manipulated for a therapeutic end.

Employing Adalimumab in Treatment of Moderate-to-Severe Hidradenitis Suppurativa: Real-Life Multicenter Data from the Czech Republic

Adalimumab is the only approved biologic treatment for moderate-to-severe hidradenitis suppurativa, nonetheless, long-term data from real-life setting are still limited. The objective of this observational multicenter study was to evaluate the effectiveness, safety, and drug survival of adalimumab in patients with hidradenitis suppurativa included in the BIOREP registry. A total of 299 patients who initiated adalimumab therapy for hidradenitis suppurativa from 2011 to November 2021 were included. The Dermatology-Life-Quality-Index (DLQI), pain scale, the number of abscesses, inflammatory nodules and draining tunnels, and International Hidradenitis Suppurativa Severity Score System (IHS4) were recorded in the 0th, 3rd, and 6th months; then every 6 months during the ongoing adalimumab treatment. Studied patients underwent treatment for up to 48 months, with the average duration of treatment lasting 2.3 years. The mean age of the patients was 44.9 years, 79% were smokers or ex-smokers, 54.8% were obese, and 26.4% were overweight, the mean BMI was 30.8. The mean time from diagnosis to initiation adalimumab therapy was 9.1 years. The number of patients with severe IHS4 dropped from the initial 249 (83.3%) to 65 (30.1%) after 12 months and this trend was maintained up to the 48th month. A decreasing number of inflammatory lesions were rapid and sustained and correlated to the improvement of patients’ quality of life, the mean DLQI score dropped from 17.6 to 8.5 after 3 months and to 5, 7 after 48 months. No unexpected risk signals were observed. Our long-term study demonstrates the effectiveness and safety of adalimumab in a real-life setting.

Adalimumab efficacy is inversely correlated with body mass index (BMI) in hidradenitis suppurativa

BACKGROUND

Adalimumab is the only FDA-approved biologic for hidradenitis suppurativa (HS). In the setting of increasing obesity rates worldwide, the relationship between adalimumab efficacy for HS and BMI is essential to understand. We assessed this relationship through markers of disease severity and inflammation.

METHODS

Institutional review board-approved retrospective chart review of Montefiore/Einstein HS Center (HSC) patients (n = 57) treated with adalimumab. The relationship between BMI and adalimumab efficacy was assessed through disease severity (HS-Physician Global Assessment [HS-PGA] 0 and Numerical Rating Scale Pain [NRS-Pain]) and inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and interleukin-6 [IL-6]). A BMI ≥ 30 is defined as obese; BMI < 30 is defined as non-obese.

RESULTS

The mean age was 35.8 ± 13.0 years. After adalimumab therapy, those with BMI < 30 experienced significant reductions in HS-PGA (-1.5 ± 0.9; P < 0.0001) and NRS-Pain (-1.6 ± 2.1; P < 0.0001), as well as mean decreases in inflammatory markers ESR, CRP, and IL-6 (-17.90 ± 23.6, -0.71 ± 1.4, -5.88 ± 7.9, respectively; P > 0.05). Obese patients (BMI ≥ 30) experienced mean increases in HS-PGA (+0.22 ± 0.8; P > 0.05) and NRS-Pain scores (+1.41 ± 3.5; P > 0.05) as well as mean increases in ESR, CRP, and IL-6 (+2.62 ± 28.3, +0.44 ± 3.0, +2.35 ± 6.9, respectively; P > 0.05). Comparing the cohorts, differences in changes in HS-PGA, NRS-Pain, ESR, and IL-6 after therapy are significantly different (P < 0.05).

CONCLUSIONS

We identified significantly lower efficacy of adalimumab in HS patients with BMI ≥ 30 compared to those with BMI < 30. Those with BMI ≥ 30 demonstrated signs of both clinical and physiological deterioration while on adalimumab. Future studies are needed to examine adalimumab dosing for HS patients with high BMI, as well as a critical reconsideration of weight-based therapies.

Hidradenitis Suppurativa: The Influence of Gender, the Importance of Trigger Factors and the Implications for Patient Habits

Hidradenitis suppurativa (HS) is a debilitating, chronic, inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. On the one hand, the presence of triggering factors-some identified, others only hypothesized-may initiate or perpetuate the pathogenic process of HS. In addition to cigarette smoking and diet, other trigger factors, including choice of clothing, are frequently observed in clinical practice. On the other hand, the presence of disease may influence habits of HS patients. Indeed, high incidences of sexual and sleep impairment have been reported in these patients. Consequently, alcohol and substance abuse may be a coping strategy for the emotional and psychological disease burden. Furthermore, a greater awareness of gender differences in HS may be important for dermatologists in their own clinical practice (i.e., pregnancy and breastfeeding). Consequently, in this loop interaction, comprehensive knowledge of all factors involved is crucial for the management of HS patients. Thus, the objective of this review is to (i) discuss the influence of gender on HS, (ii) summarize the most frequent triggering factors of HS and (iii) analyze the impact of HS on patient habits.

Mechanisms of Tumor Necrosis Factor-Alpha Inhibitor-Induced Systemic Lupus Erythematosus

Systemic lupus erythematosus induced by biologics mainly results from tumor necrosis factor-alpha remains unclear. The objectives of the study were to investigate the mechanisms of tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus. Peripheral blood mononuclear cells obtained from thirteen psoriasis patients were cultured and treated with the following: untreated control, Streptococcus pyogenes with or without different biologics. The supernatants were collected for cytokines assay. Analysis of cytokine expression revealed that IL-2 and IL-10 levels decreased only in the TNF-α inhibitor-treated groups but not in the groups treated with biologics involving IL-17, IL-12/IL-23 or IL-23 inhibitor mechanisms (p < 0.001, p < 0.05). The IFN-γ/IL-13 ratio increased significantly in patients with SLE inducing biologics to S. pyogenes induction only compared with non-SLE inducing biologics to S. pyogenes induction only (p = 0.001). IL-2 and IL-10 depletion and a shift to the Th-1 pathway in the innate response are the correlated mechanism for tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus.