Switching biologics in psoriasis - practical guidance and evidence to support

INTRODUCTION

Advances of biologic agents have changed the treatment paradigm of psoriasis to higher efficacy and better quality of life. However, the demand for biologic switch is increasing due to patient's greater expectation and decreasing efficacy in long-term use. Also, biologic-induced adverse effects necessitate the switching of biologics.

AREAS COVERED

This review article was divided into two parts. The first part focused on the biologic switch due to lack of efficacy. The second part provided switching suggestions related to adverse effects.

EXPERT COMMENTARY

Biologic switch in psoriasis was mainly due to lack of efficacy, and the subsequent biologic agent was usually given at the next scheduled time point without washout period. In pivotal randomized controlled trials, patients with poor response to TNF-alpha inhibitors and ustekinumab achieved better efficacy after switching to IL-23 and IL-17 inhibitors. In addition, real-world data showed that intra-class switch could still achieve a 50%-80% of PASI 75 response in individuals with anti-IL-17 failure histories. As for the biologic switch due to adverse effects, washout period was recommended and transition to a biologic agent with different modes of action was preferred, especially class-specific adverse events.

Positioning ustekinumab in moderate-to-severe ulcerative colitis: new kid on the block

Introduction: Ulcerative colitis (UC) is a chronic relapsing disorder of the colonic tract. Dysregulated innate and adaptive immune pathways contribute to intestinal inflammation in IBD, and cytokines, including IL-12 and IL-23, play a key role. The blockade of both IL-12 and IL-23 may have an impact on different pathways of inflammation and could be effective for the treatment of inflammatory bowel diseases.Ustekinumab is a fully human IgG1κ monoclonal antibody which binds to the shared p40 protein subunit of IL-12 and -23. It is currently approved for several immune-mediated diseases such as moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease, and has shown promising results in UC.Areas covered: A review of the literature was performed to understand several aspects including the role of IL-12 and -23 in UC, the potential therapeutic role of ustekinumab in inflammatory bowel disease, and the positioning of ustekinumab in the therapeutic algorithm of UC, based on extrapolated data from available randomized clinical trials.Expert opinion: Ustekinumab is effective and safe in UC, and shows potential advantages compared to other drugs in moderate-to-severe UC.

Functional characterization of three fish-specific interleukin-23 isoforms as regulators of Th17 signature cytokine expression in grass carp head kidney leukocytes

Mammalian Interleukin (IL)-23 is a heterodimeric cytokine with an IL-23-specific P19 subunit and a P40 subunit shared with IL-12, and plays a key role in the regulation of cell differentiation as well as inflammation. We previously demonstrated the existence of three soluble fish Interleukin (Il)-23 isoforms consist of a single P19 and one of three P40 isoforms (P40a/b/c) in grass carp. In the present study, three recombinant grass carp Il-23 (rgcIl-23) isoforms were prepared by linking gcP19 and gcP40a/b/c in a prokaryotic expression system, and then their functional properties were verified in grass carp head kidney leukocytes (HKLs). All three rgcIl-23 isoforms showed the bioactivities to divergently upregulate the mRNA expression of Th17 signature cytokines (il17a/f1, il21, il22 and il26) as well as Il-23 receptor (il23r) in HKLs. Moreover, they also promoted gcIl-17a/f1 secretion in a dose-dependent manner, strengthening their roles in Th17-like response. Furthermore, induction of il17a/f1 and il23r transcription by rgcIl-23 was blocked by a STAT3 inhibitor in grass carp HKLs, suggesting the involvement of STAT3 signaling in these inductions. Taken together, we for the first time identified the bioactivities of fish Il-23 isoforms and particularly revealed the existence of Il-23/Il-17a/f1 axis in fish, thereby advancing our understanding of Th17-like responses in fish immunity.

Growth differentiation factor (GDF-15) concentration combined with Ca125 levels in serum is superior to commonly used cancer biomarkers in differentiation of pancreatic mass

BACKGROUND

Pancreatic cancer (PDAC) will have been the second leading cancer-related death in the United States by 2020, according to current estimation. Its late manifestation and the lack of good early detection methods are the cause of extremely low survival rates. Therefore, there is an urgent need to develop highly sensitive and specific marker. GDF-15, a member of TGFbeta family, has recently emerged as a protein playing an important role in carcinogenesis of various neoplasms.

OBJECTIVE

Our aim was to assess the potential of GDF-15, IL-17, IL-23 serum concentration, and the panel of PDAC markers in differentiating pancreatic adenocarcinoma from chronic pancreatitis.

METHODS

Sixty-three consecutive patients operated on due to pancreatobiliary lesions were enrolled in this study. Levels of CEA, CA125 and Ca19-9 were assessed using standard laboratory protocols. A sample of serum was collected prior to the surgery via central line. Levels of GDF-15, Il-17, Il-23 were measured using a ELISA kit. After standard pathological examination of specimens obtained on surgery, patients were divided into 2 groups: 42 patients with pancreatic adenocarcinoma and 21 patients with focal chronic pancreatitis.

RESULTS

Mean GDF-15 concentration in patients with CP vs PDAC was 2247.95 (± 179.27) vs 7694.58 (± 1878.94) [pg/mL] respectively (p= 0.011). Mean concentration of Il-17, Il-23, Ca19-9, Ca125, Ca15-3, CEA in patients with CP and PDAC was 862.36 (± 30.84) vs 841.83 (± 33.94) p= 0.833; 127.85 (± 5.87) vs 127.51 (± 9.74) p= 0.175; 34.95 (± 23.34) vs 266.62 (± 49.7) p= 0.001; 13.4 (± 1.6) vs 39.27 (± 6.85) p= 0.005; 18.4 (± 1.48) vs 20.2 (± 1.38) p= 0.416; 1.96 (± 0.38) vs 5.93 (± 1.74) p= 0.004 respectively. In order to compare these markers with the routinely used ones, ROC curve was built. CA19-9 with clinically used cut-off point of ⩾ 36 IU/mL has specificity of 90.5% and sensitivity of 57.14%. At the same time GDF-15 with the optimal cut-off point of 2.7 ng/mL has specificity of 76.19% and sensitivity of 73.8%. Although in our research group CA19-9 has an excellent specificity, its usefulness is hampered by its low sensitivity. On the other hand, GDF-15 parameters are well-balanced making it a more useful biomarker of PDAC.

CONCLUSIONS

In conclusion, GDF-15 is more accurate than Ca19-9 in differentiating pancreatic mass due to chronic pancreatitis from pancreatic adenocarcinoma. Interleukin 17 and 23 cannot be considered as PDAC biomarkers. GDF-15 concentration in serum should be further investigated in order to assess their usefulness in pancreatic adenocarcinoma diagnosis.

Effects of anticipated neonatal surgical intervention on maternal milk cytokine production

BACKGROUND

Maternal stress on neonatal outcomes of infants admitted to the NICU is incompletely understood. We previously demonstrated breast milk derived cytokines remain biologically active in the neonatal intestine. We hypothesized that the need for neonatal surgical intervention would be stimulus leading to maternal cytokine production thus affecting neonatal outcome.

METHODS

Discarded expressed breast milk (EBM) in the first 3weeks following delivery was analyzed for IL-23 and IL-10 by ELISA. Variables analyzed included: the need for a pediatric surgical procedure, the need for cardiac surgical procedure, no surgical interventions, and survival. All values are expressed as mean±SEM. Statistical analysis utilized Kruskal and Mann-Whitney test.

RESULTS

EBM from mothers whose infants required any surgical procedure (n=19) revealed significant elevation in IL-10 but not IL-23 compared to nonsurgical EBM (n=18). Subdivided by procedure type, there was no difference between those undergoing a cardiac (n=9) versus pediatric surgical (n=10) procedure in both IL-10 and IL-23. Mothers whose infants requiring surgical intervention or whose infants did not survive in the first 3weeks of life had elevation of IL-10.

CONCLUSION

Results suggest maternal stress impacts the cytokine profile of breast milk.

LEVEL OF EVIDENCE

Level III.