Biologic and Small-Molecule Therapies for Moderate-to-Severe Psoriasis: Focus on Psoriasis Comorbidities

Psoriasis is a systemic immune-mediated disease associated with an increased risk of comorbidities, such as psoriatic arthritis, cardiovascular disease, metabolic syndrome, inflammatory bowel disease, psychiatric disorders, and malignancy. In recent years, with the advent of biological agents, the efficacy and safety of psoriasis treatments have dramatically improved. Presently, tumor necrosis factor-α inhibitors, interleukin-17 inhibitors, interleukin-12/23 inhibitors, and interleukin-23 inhibitors are approved to treat moderate-to-severe psoriasis. Small-molecule inhibitors, such as apremilast and deucravacitinib, are also approved for the treatment of psoriasis. Although it is still unclear, systemic agents used to treat psoriasis also have a significant impact on its comorbidities by altering the systemic inflammatory state. Data from clinical trials and studies on the safety and efficacy of biologics and small-molecule inhibitors provide important information for the personalized care and treatment for patients with psoriasis. Notably, treatment with interleukin-17 inhibitors is associated with new-onset or exacerbations of inflammatory bowel disease. In addition, great caution needs to be taken when using tumor necrosis factor-α inhibitors in patients with psoriasis with concomitant congestive heart failure, multiple sclerosis, and malignancy. Apremilast may induce weight loss as an adverse effect, presenting also with some beneficial metabolic actions. A better understanding of the characteristics of biologics and small-molecule inhibitors in the treatment of psoriasis comorbidities can provide more definitive guidance for patients with distinct comorbidities.

Treatment of Inflammatory Bowel Disease and Pediatric Onset Multiple Sclerosis With Ocrelizumab and Ustekinumab in a JC-virus Positive Adolescent

Inflammatory bowel disease (IBD) and multiple sclerosis (MS) are known to co-occur. Many disease modifying therapies for MS may exacerbate IBD and several carry risk of progressive multifocal leukoencephalopathy in JC-virus (JCV) positive patients. Some biologics used for IBD can exacerbate MS. These factors make comanagement of these diseases difficult. We report a 17-year-old female who presented with right leg weakness and paresthesia and was diagnosed with pediatric onset MS (POMS). She then had worsening abdominal pain and diarrhea, accompanied by weight loss, and was subsequently diagnosed with Crohn's disease. She was weakly JCV positive, so a short trial of natalizumab was initiated, which controlled her POMS well but not her IBD. Ustekinumab and ocrelizumab were initiated and achieved remission of both diseases. In the absence of established treatment guidelines, we recommend considering this combination of therapies for cases where standard treatment modalities are not viable options.

Treatment approaches to patients with multiple sclerosis and coexisting autoimmune disorders

The past decades have yielded major therapeutic advances in many autoimmune conditions - such as multiple sclerosis (MS) - and thus ushered in a new era of more targeted and increasingly potent immunotherapies. Yet this growing arsenal of therapeutic immune interventions has also rendered therapy much more challenging for the attending physician, especially when treating patients with more than one autoimmune condition. Importantly, some therapeutic strategies are either approved for several autoimmune disorders or may be repurposed for other conditions, therefore opening new curative possibilities in related fields. In this article, we especially focus on frequent and therapeutically relevant concomitant autoimmune conditions faced by neurologists when treating patients with MS, namely psoriasis, rheumatoid arthritis and inflammatory bowel diseases. We provide an overview of the available disease-modifying therapies, highlight possible contraindications, show pathophysiological overlaps and finally present which therapeutics can be utilized as a combinatory treatment, in order to 'kill two birds with one stone'.