B. Strober, MD, PhD
C. Leonardi, MD
J. Gelfand, MD
A. Blauvelt, MD
A. Kavanaugh, MD
L. Stein-Gold, MD
Newer Biologic Therapies Show Promise for Psoriasis Relief:
There has been increased focus on the IL-23/IL-17 in psoriasis and its treatment. IL-23 is upstream (targeted by tildrakizumab, guselkumab, and BI 655066), IL-17 is in the middle of the stream (targeted by ixekizumab and secukinumab), and the IL-17 receptor is downstream (targeted by brodalumab).
Efficacy of new targeted treatment options for psoriasis:
- Gesulkumab has shown excellent efficacy with PASI 75 scores approaching 80%.
- Tildrakizumab has demonstrated excellent efficacy in a phase II trial. PASI 75 scores in this study ranged from 75-80% for different tildrakizumab doses.
- BI 655066 has demonstrated remarkable efficacy after a single treatment with 54% of patients achieving and sustaining PASI 100 for 9 months.
- Secukinumab has demonstrated excellent efficacy (PASI 75 scores in >75% of patients) and a rapid onset of action (3 weeks for a mean reduction of in PASI scores).
- Ixekizumab has also demonstrated very strong efficacy (>80% of patients achieving PASI 75) and has a very rapid onset of action. It is also numerically superior to adalimumab for the treatment of PsA.
The number needed to treat (NNT) is number of patients who need a specific treatment to gain one additional good outcome (e.g., achievement of PASI 75). The best NNT is 1, where every patient experiences a benefit with the treatment The NNT for achievement of patient achieving PASI 75 is about 1 for both secukinumab and ixekizumab. They are 1.7 and 1.4, respectively, for PASI 90; and 3.6 and 2.8 for achieving PASI 100. These values are far lower (better) than those for non-biologic synthetic agents or TNF inhibitors. These new therapies mean that clearance is an achievable goal for patients with psoriasis.
There are many well-established comorbidities of psoriasis, including cardiovascular and metabolic disease. There is also increased mortality in patients with psoriasis (a 5-year reduction in lifespan). Patients with psoriasis are 30 times more likely to have a cardiovascular event than to develop melanoma. Your patients with psoriasis should be carefully evaluated for these very common conditions
Emerging comorbidities of psoriasis include chronic obstructive pulmonary disease, asthma, and chronic kidney disease. It is important to understand the entire spectrum of disease in each of your patients with psoriasis and ask questions that can uncover depression that may result from this burden.
A key question is how to identify patients with psoriasis likely to develop psoriatic arthritis (PsA). A good question to ask patients with psoriasis is, “Do you have joint pain or other joint symptoms that you want to do something about?”
Tapering therapy is an attractive approach to patient management in patients with PsA and rheumatoid arthritis (RA), but there is some evidence that stopping medication and restarting after a flare may not regain the efficacy attained prior to the treatment holiday.
It is important to understand that patients’ and physicians’ evaluation of the impact of their disease are very different and patient reported outcomes (PROs) are very important for determining “how patients do”.
Variables that significantly affect patients’ response to disease include gender and the portion of the body surface affected by psoriasis. Women are more adversely affected by psoriasis than men and the head and face are the most important parts of the body for influencing the patients’ perception of their disease severity.
It is important to keep in mind features of therapy that can affect real-world patient adherence, Maintenance regimens that are less complicated enhance the potential for increased patient adherence and successful outcomes.