Biologic Treatment Algorithms for Moderate-to-Severe Psoriasis with Comorbid Conditions and Special Populations: A Review

Abstract

The emergence of data from clinical trials of biologics, the approval of new biologics, and our improved understanding of psoriasis pathogenesis have increased the therapeutic possibilities for the treatment of moderate-to-severe psoriasis. Biologics currently approved for the treatment of psoriasis include tumor necrosis factor inhibitors, interleukin (IL)-17 inhibitors, ustekinumab (an IL-12/23 inhibitor), and IL-23 inhibitors. Data from clinical trials and studies of the safety and efficacy of biologics provide essential information for the personalization of patient care. We discuss the benefits and disadvantages of biologics as a first-line treatment choice, update treatment recommendations according to current evidence, and propose psoriasis treatment algorithms. Our discussion includes the following comorbid conditions: psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, nonmelanoma skin cancer, lymphoma, and latent tuberculosis. We make evidence-based treatment recommendations for special populations, including pediatric patients, patients with coronavirus 2019 (COVID-19), and pregnant and breastfeeding patients with psoriasis. Ultimately, individualized recommendations that consider patient preferences, disease severity, comorbid conditions, and additional risk factors should be offered to patients and updated as new trial data emerges.

Targeting Mediators of Inflammation in Heart Failure: A Short Synthesis of Experimental and Clinical Results

“…Elevated IL-17 levels were accompanied by a corresponding increase in CD4+ Th17 cell count in end-stage congestive HF (NYHA class IV) compared to the control group and patients with NYHA class I HF [ 90 ]. Three anti-IL-17 agents are currently available and recommended to treat psoriasis in patients with concomitant congestive HF [ 91 ]. Secukinumab and ixekizumab directly bind to IL-17A, whereas brodalumab occupies the IL-17 receptor A, preventing IL-17A from activating the receptor—all antagonizing the IL-17A signaling pathway [ 92 ].…”

Novel Therapeutic Approaches to Psoriasis and Risk of Infectious Disease

“…Other studies have shown that in presence of severe viral symptoms with high fever develop, the discontinuation of IL-17 inhibitors should be considered [ 120 , 121 ]. On the other hand, although IL-17 has an important role in mucosal immunity, preliminary studies by Wan et al [ 122 ] and Tathiparthi et al [ 123 ] did not prove any increased risk of either severe infection or negative outcome. Moreover, apremilast was shown having a good safety profile in COVID-19 affected patients, in fact, it does not favor either infection or cytokine storm, and it does not increase the risk of pulmonary fibrosis [ 124 ].…”

Cost per Responder Analysis of Secukinumab versus Adalimumab in the Treatment of Psoriatic Disease

“…Indeed, secukinumab was found to significantly reduce work impairment and psoriasis-associated indirect costs compared with ustekinumab and etanercept [ 35 ]. Furthermore, secukinumab has a more favorable safety profile and fewer contraindications than adalimumab [ 36 , 37 ]; for example, secukinumab carries lower risk of serious infections, demyelinating diseases, and reactivation of latent tuberculosis or hepatitis B, making it a preferred choice in some patients.…”