Biologic strategies continue to evolve

Patients who have severe psoriasis and fail conventional therapies can choose from biologic regimens that increasingly match drug attributes with individual patient characteristics, an expert says.

If the efficacy of a tumor necrosis factor (TNF) blocker starts waning, which suggests autoantibodies to the drug, dermatologists should consider switching TNF agents, said Robert E Kalb, M.D., clinical professor of dermatology, State University of New York, Buffalo, School of Medicine. "The autoantibodies will not affect the second agent." Another option, if feasible, Dr. Kalb said, is to increase the patient's dose or dosing frequency.

Some experts recommend adding methotrexate when a biologic's efficacy begins to wane. In this regard, "There's no right or wrong answer. Others have argued that you should always consider using methotrexate with a biologic drug to prevent autoantibodies," said Dr. Kalb, who spoke at the 71^st annual meeting of the American Academy of Dermatology in Miami Beach, Fla.

A recent study in patients with psoriasis shows for the first time that such a combination works better than etanercept alone (Gottlieb AB, Langley RG, Strober BE, et al. Br J Dermatol. 2012;167(3):649-657). At week 24, significantly more patients in the combination therapy group achieved Psoriasis Area Severity Index (PASI) 75 versus the etanercept monotherapy group (77.3 versus 60.3 percent; P<0.0001).

Conversely, Dr. Kalb said, if a patient fails to respond to an initial TNF therapy, data suggest switching to a drug with a different mechanism, such as the interleukin (IL)-12/IL-23 blocker ustekinumab. A recent five-year ustekinumab study showed no significant safety issues, including cancer or major adverse cardiovascular events (Papp KA, Griffiths CE, Gordon K, et al. Br J Dermatol. 2013 Jan 10. [Epub ahead of print]).