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Management


Considerations in using biologics for psoriasis


Prescriptions should be tailored to achieve the maximum benefit for each individual patient, taking into account not only speed of action of treatment, and maintenance of effect and safety considerations, but also the sustainability of reimbursement


Lluís Puig MD PhD Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain


Psoriasis is a chronic immune- mediated inflammatory disease (IMID), which can have a major impact on a patient's life. The recognition of psoriasis as a systemic disorder with associated diseases has changed treatment concepts. Comorbidity and the presence of psoriatic arthritis (PsA) are important determinants of drug selection, but prospective data demonstrating a beneficial effect of anti-psoriatic therapies on such comorbidities are largely lacking. Regular assessment of disease severity, patients’ quality of life and clinically relevant conditions (such as PsA) is mandatory in order to closely follow the course of the disease. Outcome tools should be tailored to evaluate comorbidities as well as patient-reported outcomes.1


Treatment of psoriasis, regardless of severity and duration, is generally conservative and frequently based on topical agents, which rarely clear lesions.2 Treatment with systemic agents, including biologics, is often undertaken only when topical agents have proved unsuitable, even in patients with moderate to severe disease, and conventional systemic agents are limited in their use by both acute and chronic cumulative toxicities, teratogenicity, patients’ comorbidities or convenience and, in the case of phototherapy, availability.


In other IMIDs (for example,


(PASI90) or absolute values of PASI below 2–3) can be achieved and maintained over time in the majority of patients treated with the newest anti- interleukin (IL)-17 and anti-IL-23 drugs. Of these, secukinumab has been the first to fulfil this potential and be approved in many countries and regions.4 Achievement of PASI90 response has been demonstrated to correlate with significant improvements in patient- reported outcomes with respect to PASI75;2


speed of action and


but there is a lack of evidence on how long any treatment should be given, when and how to discontinue, and which drugs would be more likely to induce long-standing remission, or which ones can be reinitiated without reducing the probability of response.


rheumatoid arthritis and Crohn's disease), targeted systemic treatment given early in the treatment pathway may improve long-term patient outcomes. A patient-centred therapeutic approach, undertaken early (early intervention) with the goal of achieving and maintaining complete, or nearly complete, clearance, may improve control of cutaneous symptoms and may also modify the disease course and lessen the disease burden,3


maintenance of response are also important considerations from both the patient’s and the prescriber’s perspectives regarding choice of treatment.


Factors affecting response to treatment


The response to biologic treatment in psoriasis patients depends on diverse factors including patient characteristics, disease-related factors and intrinsic drug characteristics. Age, sex, ethnicity, alcohol consumption, smoking, geographic location, age at diagnosis, duration and severity of psoriasis, and baseline C-reactive protein levels do not seem to consistently affect response to biologic psoriasis therapy.5


However, elderly


The ultimate goal of psoriasis treatment is complete clearance, which can be achieved in a significant proportion of patients with some of the currently available biologic agents and the new drugs under development. Nearly complete clearance (either defined by achievement of Physician's Global assessment (PGA) of 0–1, improvement of 90% or more with respect to baseline Psoriasis Area and Severity Index


patients are more likely to develop adverse events, irrespective of medication.6


Increased weight and body


mass index tend to affect response, decreasing the probability to achieve the highest degrees of response.7


This effect is


theoretically most relevant in biologics prescribed at fixed (weight-independent) dosages, though the difference in efficacy in the heavier versus the lighter patients in clinical trials is marginal, for example,


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