Biologics for psoriasis gaining ground

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, clinical associate professor of dermatology, SUNY Buffalo School of Medicine and a Buffalo-based dermatologist in private practice. Decades of experience have proven that generally, when used properly, they're very safe, and they're more cost effective than biologics, he explains.

"But what's happened is that, with standard therapies such as phototherapy with or without Soriatane (acitretin, Roche) or methotrexate, the bar has been raised higher," Dr. Kalb says.

He says he'd like to see a very good response in patients on these treatments, or else he'd likely add - or consider switching to - a biologic.

"A partial response isn't good enough anymore," Dr. Kalb states.However, he says that picking the right biologic for a given patient remains an inexact science. 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) might 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.

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, he says some patients require double dosing to maintain an adequate response. "But that also doubles the cost," Dr. Kalb says. "So I'm not a big believer in keeping patients on double-dose Enbrel.Many insurance companies won't pay for double-dose etanercept, he adds. "If that's the case," Dr. Kalb says, "adding a second treatment such as phototherapy or acitretin, or possibly switching to adalimumab or infliximab, may be more cost effective."

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) might be effective because these drugs offer different mechanisms of action, he says.

Dermatologists also should consider that psoriasis often is a precursor to PSA, Dr. Kalb tells Dermatology Times E-News. "We may be the first physician to discover the (psoriasis) patient is experiencing joint symptoms - and early intervention in PSA can be important. The presence of significant PSA is one situation where the TNF-inhibiting biologics may be considered first-line therapy."

When prescribing biologics, dermatologists also must weigh the possible risk of lymphoma (primarily among TNF blockers) and of serious infection, he says. However, Dr. Kalb says that in his experience, biologic drugs over time can reduce patients' need for long-term systemic therapies such as cyclosporin and methotrexate.

Disclosure: Dr. Kalb has served as an investigator and/or consultant for Abbott, Amgen, Biogen, Centocor, Connetics, Genentech and Warner-Chilcott.

Dr. Kalb's entire presentation is in FOC 601 from 7:15 to 8:45 a.m. on July 27.