Using biologics to treat psoriasis

Dr. Menter presented "Biologics Update" at the Fall Clinical Dermatology Conference, here.

He gave a review of his clinic patients, a large tertiary referral center, which has approximately 460 patients undergoing treatment with biologics. He discussed currently available biologics in terms of efficacy and safety and gave a review of currently available data, and focused on the efficacy data but also discussed the safety data.

Need for biologics

Although these agents have been very effective for many years, there are certain patients who cannot tolerate treatment with methotrexate and/or cyclosporine or have other pre-existing conditions that may prevent them from treatment with these drugs. Patients with hepatitis C, abnormal liver function, bone marrow issues or those who wish to get pregnant within several months are not candidates for methotrexate therapy. Also, patients with kidney and blood pressure problems are not eligible for cyclosporine treatment. In these patients, biologic therapy is a welcomed option.

Why biologics, which are much more expensive than traditional agents? Psoriasis is not considered a short-term disease; therefore, the medical community needs to look at the safe, long-term control of this chronic disease that has such a negative impact on quality of life.

"I think in the past we have used these traditional agents but when faced with side effects and the need to do a liver biopsy with methotrexate there may be an advantage to transition patients to a drug that may not have the same liver complication and toxicity or bone marrow issues that methotrexate may have or the blood pressure or kidney issues that cyclosporine may have. Also, cyclosporine is only approved for one year of continuous use, so what do you do when that one year is finished?"

A larger choice of drugs is needed, and Dr. Menter says that he hopes that long term use of biologic drugs will essentially be safer than previous therapies.

Biologics: efficacy

Currently, there are five biologics approved for treatment of psoriasis. These are alefacept and efalizumab which are categorized as T-cell agents, and the TNF–alpha drugs, which are adalimumab, etanercept and infliximab.

Dr. Menter says that alefacept gives a low primary endpoint of 21 percent after 12 weeks, but that it is the one drug dermatologists have that, in a small percentage of patients, gives remissions that may last up to six months or longer.

"I wish we had a way of actually predicting which patients would be the ones who would have the long term remission because we do not have other drugs that give this long term remission. However, for the first course of therapy it does not work great and we typically need adjunctive treatments like phototherapy to improve it," Dr. Menter explains.