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Advancing Knowledge. Enhancing Care.

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EADV 2020 | How to Deal With the Forest of Biologics in Psoriasis

Biologics 2020

Presented by Christopher Griffiths, OBE, MD, FRCP, FMedSci

 

A report from the 29th Congress of the European Academy of Dermatology and Venereology


With an ever-enlarging armamentarium of biologic treatments, considering each individual patient and collecting real-world data is of utmost importance in achieving optimal, personalized therapies.

TNF-inhibitors (TNFi) have long-term efficacy and safety profiles, and biosimilars now increase the scope of use across specialties. Key considerations prior to treatment include TB status, demyelinating disease, cardiac failure, infection, and antidrug antibodies. Notably, TNFi remain the gold standard for psoriatic arthritis (PsA), and certolizumab can be used in pregnancy.

Newer biologics carry lower risk of infections and exhibit increased PASI response, but often lack extensive real-world data. Anti-IL-17 drugs including ixekizumab, secukinumab, and brodalumab (the only IL-17 receptor inhibitor) have excellent PASI-90 response, often exceeding 70%. Importantly, this class succeeds after TNFi failure and is effective in spondyloarthropathy and PsA. Adverse effects (AEs) are often mild-moderate, but candida and IBD exacerbation are important known AEs. Of note, there is an uncertain association between brodalumab and suicidality.

Anti-IL-23 includes ustekinumab (IL-23p40) and the newer, more effective anti-IL-23p19 medications risankizumab, guselkumab, and tildrakizumab. These p19 drugs demonstrate exceptional PASI-90 response of 70-80% and PASI-100 often reaching 50%. They are also disease modifying; one injection may lead to remission. Trials have shown no consistent disconcerting AEs, and unlike anti-IL-17, there carry no candidiasis or IBD risk.

With this vast array of options, Dr. Griffiths emphasizes that the future is targeted therapy. As examples, adalimumab serum levels ≥ 7 µg/mL can achieve excellent PASI-75 response in 81% of patients, and ustekinumab has higher PASI-90 response if the patient is HLA-Cw6+.23-24 Using large databases and Drug Endotypes (signatures), we continue gaining vital knowledge to predict who is the right candidate for each drug. 

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