Two views on biologics

There has been much buzz in the news recently about the use of biologics for the treatment of psoriasis. But what are the pros and cons of these treatments, and how should they fit into physicians' armamentaria? Dermatology Times asked Staff Correspondent Lisa Samalonis to speak with Norman Levine, M.D., professor of medicine at the University of Arizona College of Medicine, and M. Alan Menter, M.D., Texas Dermatology Associates PA, Baylor University Medical Center, for their input.

Q. What are the advantages of biologics for the treatment of psoriasis?

Dr. Levine

Dr. Menter

The biologics are effective for moderate to severe psoriasis. Two of them, adalimumab and infliximab, are currently approved for psoriatic arthritis. In addition, infliximab is expected to be approved for psoriasis in 2006 and adalimumab in 2007.

The question is: Why haven't enough patients been treated with them? We have to recognize that rheumatologists have been using the TNF-alpha inhibitors, infliximab, etanercept and adalimumab for over five years. These are life-changing drugs that improve the quality of life for people with Crohn's disease and rheumatoid arthritis.

There should not be any controversy as to why they should not be equally used for the eligible patients who have moderate-to-severe psoriasis whose quality of life is as equally devastated as those patients with Crohn's disease or rheumatoid arthritis. I feel very strongly that we as dermatologists should not take a backseat in the biologic therapy arena or that psoriasis patients should be treated any differently than patients with rheumatoid arthritis or Crohn's disease. The quality of life is as miserable and devastating as those two diseases plus multiple sclerosis, sometimes mentally even more devastating.

The biologic drugs are very useful to patients who cannot take methotrexate, cyclosporine or acitretin because of pregnancy issues or other pre-existing conditions such as hepatitis C, diabetes or hypertension.

Q. What are the disadvantages of this group of drugs for psoriasis?

Dr. Levine

These drugs are ridiculously expensive. We, as physicians, have to take society into account when we make treatment decisions. We are, in effect, prescribing drugs that cost as much for one year of therapy as a small automobile.

Although most of these drugs are now covered by insurance, this is not a good enough reason to choose these agents. Insurance companies may wind up paying for the care for a lot of patients who have psoriasis, but who may not need this type of treatment. In many patients, an effective therapy which is much less expensive often works just as well. We all pay for costly treatments. The insurance carriers simply pass along the cost to the rest of us, and that is a serious issue to consider before embarking on a course of treatment.

With that in mind, in my view, these drugs are first-line therapy for only a relatively few patients. We have very good treatments that can be used to improve many cases of severe psoriasis that require systemic therapy, and we have had them for 40 or more years. Considering all the risks, benefits and economic issues, my conclusion is that dermatologists should not immediately use the biologics until they have tried the other systemic therapies.

Another reservation about using these drugs is that certain patients do well, but many patients do just fairly well. If someone is going to do just OK, there are many other non-biologic, more affordable treatments to use first.