Switching biologics in psoriasis

In the absence of guidelines for switching biologic psoriasis drugs, a new commentary suggests possibly starting with the longest-lasting agents and reserving older drugs as rescue therapies when possible.

The commentary appeared online in the August 2018 British Journal of Dermatology by Joerg Albrecht, M.D., of Cook County Health and Hospital System in Chicago.

Healthcare providers look for a certain degree of deterioration as a threshold for change in treatment when there appears to be no signs of improvement or the disease is recurrent. Providers distinguish between approaches toward different subtypes of psoriasis such as guttate, inverse or nail psoriasis, but there is little clinical guidance on how to fine-tune biologic treatment for plaque psoriasis that include specific patient characteristics, wrote Albrecht et al.

After switching occurs, it takes a while for the patient to cross the threshold in the other direction. "So every time you switch, the patient is miserable for at least four months. If we have a medication that we know will work for the next seven years, which all of these medications can do in some people, you can avoid these failures and choose the most efficient drugs to start therapy," Dr. Albrecht said.
Although an FDA-mandated trial of increasing ustekinumab dosing intervals exists, physicians have not yet worked out what long-term biologic-sparing regimens should look like, he said.

AMAGINE-2 and AMAGINE-3

The commentary was written in response to an analysis of the AMAGINE-2 and AMAGINE-3 data published online February 2018 in the British Journal of Dermatology in which researchers investigated the impact of previous biologic exposure on the efficacy and safety of brodalumab and ustekinumab in patients with moderate-to-severe plaque psoriasis.

The theory was that biologics may wane with previous exposure to biologics, but researchers ― who were led by Kim A. Papp, M.D., of Probity Medical Research in Ontario ― found that brodalumab was just as effective in new patients as compared to those who received prior biologic therapy.

In short:
• Twice as many patients on brodalumab achieved 100% improvement PASI 100 as compared with ustekinumab regardless of whether they tried previous biologics.
• For patients who failed previous biologics, the benefit of brodalumab was three times greater than patients receiving ustekinumab.
• Safety results were similar in both new and established patients receiving biologics.

THE DETAILS
This study shows that efficacy rates for brodalimumab and ustekinumab in patients with or without previous biologic exposure were statistically equivalent: the proportions of biologic-naive and -experienced patients in the brodalimumab cohort who reached Psoriasis Area and Severity Index (PASI) 100 at week 12 were 40.9 percent and 39.5 percent, respectively. The corresponding figures for ustekinumab-treated patients were 21.1 percent and 17.0 percent (p<0.001 in both analyses). In patients for whom prior biologics had succeeded or failed, 41.7% and 32.0% of brodalimumab-treated patients achieved PASI 100, respectively, as did 21.1 percent and 11.3 percent of ustekinumab-treated patients.

DISCLOSURES
Dr. Albrecht is a clinical investigator for AbbVie and AiCuris.

REFERENCES
K.A. Papp,  K.B. Gordon, R.G. Langley, et al. "Impact of previous biologic use on the efficacy and safety of brodalumab and ustekinumab in patients with moderate‐to‐severe plaque psoriasis: integrated analysis of the randomized controlled trials AMAGINE‐2 and AMAGINE‐3," British Journal of Dermatology. Feb. 28, 2018. https://doi.org/10.1111/bjd.16464

Joerg Albrecht MD, Sascha Gerdes MD. "Put the Ducks in a Row - Which Biologic to Use First?" British Journal of Dermatology. August 2018.