An evidence-based review of the mechanism of action, efficacy, and safety of biologic therapies in the treatment of psoriasis and psoriatic arthritis

Biologic agents have expanded the repertoire of efficacious and safe systemic therapies for the treatment of moderate-to-severe psoriasis and active psoriatic arthritis. The biologics act to inhibit key inflammatory molecules that are thought to be involved in the pathogenesis of these chronic inflammatory disorders as well as physiologic immune responses. In this paper, we discuss the proposed molecular mechanisms of action, efficacy, and safety of the two FDA-approved classes of biologics, the tumor necrosis factor inhibitors and the interleukin-12/23 inhibitor. The tumor necrosis factor inhibitors that are reviewed include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol. The interleukin- 12/23 inhibitor that is discussed is ustekinumab. Specifically, we review the mechanism of action for each biologic agent and the FDA-approved indications and dosing for these therapeutics. We provide up-to-date evidence for the efficacy of these systemic medications using key phase 3 clinical trial data, we highlight important safety information for each biologic based on long-term open-label extension trials and safety registries, and we discuss studies that investigate off-label dosing with the biologics. Each biologic is reviewed in these specific areas of focus for their indicated treatment of psoriasis and/or psoriatic arthritis.

Economic Burden of Psoriasis in the United States: A Systematic Review

IMPORTANCE

The total cost of psoriasis in the United States is unknown. Defining the US economic burden of psoriasis is needed because it provides the foundation for research, advocacy, and educational efforts.

OBJECTIVE

To determine the US economic burden of psoriasis from a societal perspective.

EVIDENCE REVIEW

PubMed and MEDLINE databases were searched between January 1, 2008, and September 20, 2013, for economic investigations on the direct, indirect, intangible, and comorbidity costs of adult psoriasis in the United States. The base year costs were adjusted to 2013 US dollars using the Consumer Price Index for All Urban Consumers and multiplied by the estimated number of US patients with psoriasis in 2013 to determine the 2013 psoriasis cost burden.

FINDINGS

Among 100 identified articles, 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. Patients with psoriasis would pay a lifetime cost of $11,498 for relief of physical symptoms and emotional health; however, intangible cost data are limited. The annual US cost of psoriasis amounted to approximately $112 billion in 2013.

CONCLUSIONS AND RELEVANCE

The economic burden of psoriasis is substantial and significant in the United States.

Updates in adult-onset Still disease: Atypical cutaneous manifestations and associations with delayed malignancy

Adult-onset Still disease (AOSD) is a systemic inflammatory disorder that is clinically characterized by a heterogeneous constellation of symptoms and signs. Though an evanescent eruption is the classic cutaneous finding, recent literature has highlighted atypical rashes associated with Still disease. A second emerging concept in presentations of AOSD is its association with malignancy. This review focuses on these concepts: the clinical spectrum of atypical skin manifestations and AOSD as a paraneoplastic phenomenon. PubMed-MEDLINE was screened for peer-reviewed articles describing atypical presentations of AOSD and cases associated with malignancy. Erythematous, brown or violaceous, persistent papules and plaques were the most common cutaneous finding (28/30 [93%]). Linear configurations were also rarely described. Of these patients, 81% concurrently had the typical evanescent skin eruption. There were 31 patients with associated malignancies, most commonly breast cancer and lymphoma. The diagnosis of malignancy did not precede or immediately follow a clinical presentation otherwise consistent with AOSD in a considerable subset of patients (42%). Understanding the cutaneous spectrum of AOSD and heightened awareness for its delayed association with malignancy may lead to improved recognition of cutaneous variants and reinforce the need for diagnostic evaluation and long-term follow-up for malignancy in patients with this clinical presentation.

Effects of biologic agents and other disease-modifying antirheumatic drugs on cardiovascular outcomes in psoriasis and psoriatic arthritis: a systematic review

BACKGROUND

Whether systemic treatments for psoriasis or psoriatic arthritis affect cardiovascular comorbidities is a clinically significant question.

OBJECTIVE

To examine the effects of biologic agents and other Disease-Modifying Antirheumatic Drugs (DMARDs) used to treat psoriasis and psoriatic arthritis on cardiovascular risk factors and adverse cardiovascular outcomes.

METHODS

MEDLINE (1980-October 2012), Web of Science, the EULAR abstract database, and the AAD annual meeting abstract archive were searched for studies evaluating biologic and other DMARD therapy for psoriasis and psoriatic arthritis that reported cardiovascular events as primary outcomes.

RESULTS

From 20 studies that met the search criteria for the review, 81,469 patients with psoriasis and/or psoriatic arthritis were included in the data synthesis of the current literature. While the data on the cardioprotective effect of methotrexate exist in patients with rheumatoid arthritis, its effect on the psoriasis and psoriatic arthritis populations with regards to cardiovascular outcomes are inconclusive at this time. The association of hypertension with long-term cyclosporine use prompts discontinuation of cyclosporine in selected patients. The use of TNF inhibitors may be associated with reduced risk of adverse cardiovascular events in preliminary epidemiologic studies; however, large randomized controlled trials and epidemiologic studies with well-characterized populations will be necessary to elucidate their exact effects. The short-term data regarding the safety of IL-12/23 inhibitors showed that, to date, there are no increased cardiovascular events compared to the general population.

CONCLUSIONS

To date, epidemiologic data is insufficient to reach definitive conclusions with regards to the effects of biologics and other DMARDs on cardiovascular outcomes in psoriasis and psoriatic arthritis patients. Adequately powered, long-term, controlled studies are necessary to determine the cardioprotective effects of TNF inhibitors observed in preliminary studies on psoriasis and psoriatic arthritis populations.

Public perception of dermatologists and comparison with other medical specialties: results from a national survey

BACKGROUND

The public's perception of dermatologists in the United States is unknown.

OBJECTIVE

We sought to determine the US public's perception of how dermatologists spend time professionally and to compare the public's perception of dermatologists with physicians from other medical specialties.

METHODS

We administered a telephone survey to the US public using the validated random digit dialing method.

RESULTS

We made 2353 telephone calls to randomly selected active numbers from 10 US area codes. A total of 800 adults (34%) completed the telephone survey. Overall, 46% of participants perceived that dermatologists spend a majority of their time managing skin cancer. Of respondents, 27% perceived that dermatologists spend a majority of their time performing cosmetic procedures. Compared with dermatologists, primary care physicians were perceived to have a more critical profession by 63% of participants, a more difficult job by 54% of respondents, and work longer hours by 92% of those surveyed. Similar findings were observed when dermatologists were compared with cardiologists. The public perceived dermatologists to earn more than primary care physicians but less than cardiologists or plastic surgeons.

LIMITATIONS

Potential differences may exist between responders and nonresponders.

CONCLUSIONS

Educational efforts are necessary to better inform public understanding and perception of dermatologists' expertise.

Getting to the point: a case of a sewing needle retrieved from the thigh

Foreign bodies are rarely retained in the skin after puncture wounds or impalement injuries and are even less commonly initially detected several months after penetration. Sewing needles are most frequently reported in the literature as foreign bodies in cases of ingestion, inoculation of the cranium and heart, and penetration of the knee. Herein we describe a case of a middle-aged man who presented to the outpatient dermatology clinic with an 8-month history of a nodule in his left thigh; he had noted recent onset of mild pain. On examination he was found to have a sharp needle-like point palpable below the skin of his left lateral thigh. Plain radiographs of the left thigh showed a fractured sewing needle overlying the same area. During local incision, two fragments of a sewing needle were removed from the lateral thigh.

Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids

OBJECTIVE

To identify whether nutrient supplementation with probiotics, prebiotics, formula, or fatty acids prevents the development of atopic dermatitis (AD) or reduces the severity of AD in newborns to children younger than 3 years.

DATA SOURCES

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and LILACS (Latin American and Caribbean Health Science Literature) from January 1, 1946, to August 27, 2012, and performed an additional manual search.

STUDY SELECTION

Randomized controlled trials and cohort studies examining nutritional supplementation in prevention and amelioration of AD among children younger than 3 years.

DATA EXTRACTION

Of 92 articles, 21 met inclusion criteria.

DATA SYNTHESIS

In the 21 studies, a total of 6859 participants received supplements, which included infants or mothers who were either pregnant or breastfeeding;4134 infants or mothers served as controls. Nutritional supplementation was shown to be an effective method in preventing AD (11 of 17 studies) or decreasing its severity(5 of 6 studies). The best evidence lies with probiotics supplementation in mothers and infants in preventing development and reducing severity of AD. Specifically, Lactobacillus rhamnosus GG was effective in long-term prevention of AD development. γ-Linolenic acid reduced severity of AD. Supplementation with prebiotics and black currant seed oil (γ-linolenic acid and ω-3 combination) was effective in reducing the development of AD. Conflicting findings were reported from different research groups that performed supplementation with an amino acid–based formula.

CONCLUSIONS

Certain types of nutrient supplementation are beneficial in preventing AD development and reducing its severity. Future research elucidating the mechanisms underlying the actions of nutritional supplementation on AD is necessary.

Off-label biologic regimens in psoriasis: a systematic review of efficacy and safety of dose escalation, reduction, and interrupted biologic therapy

OBJECTIVES

While off-label dosing of biologic treatments may be necessary in selected psoriasis patients, no systematic review exists to date that synthesizes the efficacy and safety of these off-label dosing regimens. The aim of this systematic review is to evaluate efficacy and safety of off-label dosing regimens (dose escalation, dose reduction, and interrupted treatment) with etanercept, adalimumab, infliximab, ustekinumab, and alefacept for psoriasis treatment.

DATA SOURCES AND STUDY SELECTION

We searched OVID Medline from January 1, 1990 through August 1, 2011 for prospective clinical trials that studied biologic therapy for psoriasis treatment in adults. Individual articles were screened for studies that examined escalated, reduced, or interrupted therapy with etanercept, adalimumab, infliximab, ustekinumab, or alefacept.

DATA SYNTHESIS

A total of 23 articles with 12,617 patients matched the inclusion and exclusion criteria for the systematic review. Data were examined for primary and secondary efficacy outcomes and adverse events including infections, malignancies, cardiovascular events, and anti-drug antibodies. The preponderance of data suggests that continuous treatment with anti-TNF agents and anti-IL12/23 agent was necessary for maintenance of disease control. Among non-responders, dose escalation with etanercept, adalimumab, ustekinumab, and alefacept typically resulted in greater efficacy than standard dosing. Dose reduction with etanercept and alefacept resulted in reduced efficacy. Withdrawal of the examined biologics led to an increase in disease activity; efficacy from retreatment did not result in equivalent initial response rates for most biologics. Safety data on off-label dosing regimens are limited.

CONCLUSION

Dose escalation in non-responders generally resulted in increased efficacy in the examined biologics used to treat moderate-to-severe psoriasis. Continuous treatment with anti-TNF agents and anti-IL12/23 agent results in superior efficacy over interrupted therapy. The decision to use off-label dosing needs to account for both benefits and risks and be individualized to patients' disease severity, quality of life, and existence of comorbidities.

Are patients with psoriasis being screened for cardiovascular risk factors? A study of screening practices and awareness among primary care physicians and cardiologists

INTRODUCTION

Increasing literature suggests that patients with psoriasis who have severe disease appear to have increased frequency of cardiovascular (CV) diseases. The National Psoriasis Foundation recommends screening for CV risk factors as early as 20 years of age. The extent to which these screening guidelines are implemented in practice is unclear.

OBJECTIVE

We sought to assess CV risk factor screening practices in patients with psoriasis and to assess primary care physician (PCP) and cardiologist awareness of worse CV outcomes in patients with psoriasis.

METHODS

We distributed 1200 questionnaires to PCPs and cardiologists between October 1, 2010, and April 15, 2011. A representative national sample of physicians was obtained by random selection from professional medical societies.

RESULTS

A total of 251 PCPs and cardiologists responded to the questionnaire. Among these physicians, 108 (43%) screened for hypertension, 27 (11%) screened for dyslipidemia, 75 (30%) screened for obesity, and 67 (27%) screened for diabetes. Physicians who cared for a greater number of patients with psoriasis were significantly more likely to screen for CV risk factors (hypertension P = .0041, dyslipidemia P = .0143, and diabetes P = .0065). Compared with PCPs, cardiologists were 3.5 times more likely to screen for dyslipidemia (95% confidence interval 1.32-9.29, P = .012). A total of 113 (45%) physicians were aware that psoriasis was associated with worse CV outcomes.

LIMITATIONS

The questionnaire response rate was modest.

CONCLUSIONS

Most PCPs and cardiologists did not routinely screen patients with psoriasis for CV risk factors. Educating physicians regarding potentially increased CV risk in psoriasis and adopting a multidisciplinary approach in the care of patients with psoriasis will likely lead to improved patient outcomes.