Commentary: Drug Survival Associated with Effectiveness and Safety of Treatment with Guselkumab, Ixekizumab, Secukinumab, Ustekinumab, and Adalimumab in Patients with Psoriasis

In recent years, clinical trials of drugs, such as interleukin (IL)-17 and IL-23 inhibitors, have shown remarkable levels of sustained long-term clearance of psoriasis. However, a fundamental limitation of clinical trials is that the patients included in such trials are not always representative of patients seen in daily clinical practice. Only about one-third of “real-life” patients are eligible for inclusion in a clinical trial. Moreover, comorbid diseases, physician behaviors, dose modifications, regional guidelines, payer policies, and prescribed co-medication may all influence the effectiveness and safety of biologics in daily clinical practice.

In daily practice, loss of response over time is often observed. Although the reasons are still not fully understood, this degree of “biologic fatigue” appears to differ between the different biologics. The term “drug survival” refers to the probability that a patient will remain on treatment and is a critical proxy measure of effectiveness in real-life settings.

The present study examined drug survival among 16,122 treatment courses of biologic therapy with either guselkumab, ixekizumab, secukinumab, ustekinumab, or adalimumab, using United Kingdom registry data. The authors found that guselkumab had the highest drug survival concerning effectiveness and safety. Notably, the authors also found that the effect of biologic therapy was modified by factors such as the presence of psoriatic arthritis, prior exposure to biologic therapy, current nail psoriasis, and ethnicity, thus highlighting that “one size does not fit all” when it comes to treating psoriasis.

Significantly, however, treatment patterns may change over time, and a patient is more likely to, e.g., discontinue adalimumab in the present day compared with twenty years ago, when alternatives were much more limited. The study adds to the growing list of real-world studies suggesting that novel biologics, such as the IL-23 inhibitor guselkumab, have a higher drug survival in psoriasis. Still, there remains an essential need for “personalized evidence,” i.e., predictors showing which patient profiles will benefit the most from a specific biologic.