Biologics gain ground as treatment option

While biologic drugs may not provide a first-line treatment for psoriasis, dermatologists are reaching for them somewhat more readily, an expert says.

When treating psoriasis, dermatologists should usually use conventional therapies first, says Robert E. Kalb, M.D., clinical associate professor of dermatology, State University of New York Buffalo School of Medicine and a Buffalo-based dermatologist in private practice. Decades of experience have proven that generally, when used properly, biologics are very safe, he explains.

However, he says that picking the right biologic for a given patient remains an inexact science.

"Unfortunately, we still don't know which biologic is best in which situation," or in what order to rank biologic drugs' effectiveness, he says.

GUIDELINES EMERGE

Fortunately, some general guidelines are emerging, albeit through anecdotal reports.

For instance, Dr. Kalb says, "There is some data suggesting that for heavier patients, it may be more effective to use a drug with weight-based dosing." Likewise, he says research suggests that if a patient has very significant skin disease, a monoclonal antibody such as Humira (adalimumab, Abbott) or Remicade (infliximab, Centocor) may work best.

"Etanercept (Enbrel, Amgen/ Wyeth) was approved first (for psoriatic arthritis, PsA), so most physicians have the highest comfort level with it," Dr. Kalb says. Etanercept also minimizes laboratory monitoring requirements, and patients can usually start and stop therapy without difficulty, he adds. "Physicians' comfort level shows in the actual prescriptions written, where etanercept is used probably 8 to 1 over everything else at this point," Dr. Kalb says.

Although etanercept's manufacturer recommends giving patients 50 mg twice a week for the first 12 weeks, then cutting back to 50 mg once weekly, Dr. Kalb says some patients require double dosing to maintain an adequate response.

"But that also doubles the cost" to more than $40,000 per patient, he says. Many insurance companies won't pay for double-dose etanercept, he adds.

"If that's the case," he says, "adding a second treatment such as phototherapy or acitretin, or possibly switching to adalimumab or infliximab, may be more cost-effective."

Whether one starts at 50 mg weekly or twice weekly, Dr. Kalb says, "One gets to the same point in a year anyway, so starting out at the higher dose is often not necessary. Unless the patient needs more of a quick response or the psoriasis is somewhat unstable, I tend to start at 50 mg once a week."

There's some anecdotal evidence that if a patient fails a TNF blocker such as etanercept, infliximab or adalimumab, switching to a non-TNF blocker such as efalizumab or possibly Amevive (alefacept, Biogen Idec) might be effective because these drugs offer different mechanisms of action, he says.

PSORIATIC ARTHRITIS

Dermatologists also should consider that psoriasis often is a precursor to PsA, Dr. Kalb says.

"Even though biologic drugs are approved for PsA," he says, "most dermatologists don't treat arthritis." However, if a patient under treatment for psoriasis has never seen a rheumatologist, he says, "We may be the first physician to discover the patient is experiencing joint symptoms - and early intervention in PsA can be important.