Expert Advises How to Address Biologic Failure in Psoriasis

By Denise Fulton, Frontline Medical News

NEWPORT BEACH, CALIF. – What’s a dermatologist to do when a psoriasis patient has been very well controlled on a biologic for a number of years, but then the disease returns? Dr. Jashin Wu, director of the psoriasis clinic at Kaiser Permanente Los Angeles Medical Center, shared his experience with this situation at the PDA 2016 Annual Meeting.

Dr. Wu presented the case of a 45-year-old man diagnosed with psoriasis in 2008. The patient’s psoriasis was severe, covering 50% of his body surface area (BSA). He had previously failed treatment with topical therapies, methotrexate, and UVB phototherapy.

Dr. Wu started the patient on adalimumab with great success. “He was very clear, very happy [with the result]. He had never been on a biologic before and never really been this clear before – he went down to body surface area 0,” Dr. Wu said, adding that the patient was maintained on adalimumab monotherapy 40 mg biweekly for 5 years.

Shortly after, the patient noticed a recurrence of psoriatic lesions on his lower legs, with about 3% of body surface area involved, Dr. Wu said, adding that this pattern of recurrence is fairly common.

“There are some studies, mostly lead by Dr. Joel Gelfand [professor of dermatology at the University of Pennsylvania], that indicate that once patients are clear, they want to stay clear. Even if they just get 1% body surface area involvement, they are really quite worried about that – they’re afraid they are going to go back to their original baseline. Once they are clear, we have to try our best to help them remain clear.”

Drug survival can serve as a proxy of a biologic’s safety and efficacy in the real world setting and varies among the currently used biologics, he said.

“Say for example a patient is on etanercept and they’re doing well for a while, but the drug loses effect over time. That means a drug failure. Or a patient is on adalimumab and gets cellulitis and they have to stop that. That’s a drug failure,” Dr. Wu said. “Or even if they can no longer afford the medicine; that in ways is a drug failure as well.”

Dr. Wu and his colleagues looked at drug survival in all psoriasis patients treated with adalimumab at their institution. Of 79 biologic-naïve patients with severe psoriasis, 42 (53.2%) persisted on adalimumab therapy through the end of the study – from 13 months to almost 7 years. The remaining patients who had to stop were treated with adalimumab alone for an average of almost 18 months before they failed treatment. Mean drug survival was 3.7 years. Failure was defined as the need to add an oral agent or phototherapy or switch to a different systemic agent (J Am Acad Dermatol. 2016 Mar; 74:575-577).

Other investigators also have looked at drug survival with biologics. In the British Association of Dermatologists Biologic Interventions Register (BADBIR), patients on etanercept were more likely to stop therapy than were those on adalimumab (hazard ratio, 1.63), as were patients on infliximab (HR, 1.56). Conversely, patients on ustekinumab were more likely to continue therapy (HR 0.48).

Because each of these treatments may lose efficacy over time, Dr. Wu chose not to switch his adalimumab patient to another biologic immediately. He first added low-dose methotrexate (20 mg per week), and the patient’s psoriasis remained under control for an additional 2 years. When breakthrough continued, the patient was eventually switched to secukinumab and is again controlled with a 0% BSA after 12 months.

“I think it’s best to try to extend [a patient’s] biologic as long as possible,” Dr. Wu added. “You probably don’t want to cycle through all the biologics right away. If they fail one after another, you really don’t have any options left.”

Dr. Wu disclosed no personal financial conflicts of interest; however, he noted that his institution has relationships with many makers of biologics for psoriasis.