The road to biologics in patients with hidradenitis suppurativa: a nationwide drug utilization study

Abstract

Background Prolonged systemic antibiotic treatment is often a part of management of hidradenitis suppurativa (HS). Although biologic therapies are now available, the patient's treatment journey leading to biologic therapy is unclear. Objectives To examine treatment patterns and duration of systemic treatment use in patients with HS preceding biologic therapy. Methods We identified all patients with HS receiving treatment with biologics in the Danish National Patient Registry from 2010 to 2018 and extracted their entire prescription history of specific systemic treatments from the Danish National Prescription Registry since its inception in 1995. The patients' treatment journeys are graphically displayed through Sankey diagrams and box plots generated to show temporal distributions. Descriptive patient characteristics were presented as frequencies with percentages for categorical variables and as means with SDs or medians with interquartile ranges (IQRs) for continuous variables. Results A total of 225 patients with HS were included. Patients had most frequently been treated with penicillin (n = 214; 95Á1%), dicloxacillin (n = 194; 86Á2%), tetracycline (n = 145; 64Á4%) and rifampicin/clindamycin (n = 111; 49Á3%), as well as the retinoids isotretinoin and acitretin, and dapsone. Prior to biologic therapy, patients received a mean of 4Á0 (SD 1Á3) different systemic therapies, across a mean of 16Á9 (SD 11Á3) different treatment series. The mean time from first systemic therapy until biologic therapy was initiated was 15Á3 (SD 5Á1) years [8Á2 (SD 5Á9) years when excluding penicillin and dicloxacillin]. Conclusions Patients with HS who receive biologic therapy have long preceding treatment histories with multiple drug classes and treatment series, many of which are supported by relatively weak evidence in HS. Delay in the initiation of biologic therapy may represent a missed opportunity to prevent disease progression.What is already known about this topic?• The treatment journey leading to biologic therapy in patients with HS has not previously been investigated.

Noticeability of vitiligo is in the eye of the beholder

“…Improvement of vitiligo in clinical studies has usually been measured by assessing repigmentation of individual lesions as well as overall reduction of body surface area affected by vitiligo. 1 However, even after achieving significant repigmentation, vitiligo lesions may still be quite noticeable to others, contributing to the considerable psychological impact of this disorder. Statistically significant improvement in trials may not be meaningful to affected individuals, especially those with lesions in exposed areas and darker skin types.…”

“…Further research should be performed to develop PROMs that are static and measure improvement in all vitiligo lesions in a single patient. 1 Even though adalimumab is currently the only approved treatment for HS, patients received a mean of 4Á0 different systemic therapies, and the mean time from first systemic therapy until biologic therapy was initiated was 15Á3 years.…”

“…European guidelines recommend that antibiotics should be used for up to 3 months and reintroduced in case of recurrence, under the requirement that they were effective at the last time of use. 1 Recent evidence suggests that there is no significant difference between treatment with tetracyclines or clindamycin plus rifampicin in validated outcomes after 12 weeks, regardless of disease severity, so tetracyclines should be the first-line treatment in moderate-to-severe disease. 8 Upon failure of these agents, adalimumab should be considered, which has evidence for efficacy and safety with long-term use and combination with surgery as well.…”

Implementing evidence-based strategies to optimize the journey of patients with hidradenitis suppurativa

“…I read with great interest the report of Ring et al . and the evidence from the Danish National Patient Registry analysis, which shows that patients with hidradenitis suppurativa (HS) who receive biologic therapy have long preceding treatment histories with multiple drug classes and treatment series, many of which are supported by relatively weak evidence in HS or not supported at all 1 . Even though adalimumab is currently the only approved treatment for HS, patients received a mean of 4·0 different systemic therapies, and the mean time from first systemic therapy until biologic therapy was initiated was 15·3 years.…”

“…In patients with Hurley stage II/III HS presenting with several active lesions, systemic clindamycin and rifampicin should be considered. European guidelines recommend that antibiotics should be used for up to 3 months and reintroduced in case of recurrence, under the requirement that they were effective at the last time of use 1 . Recent evidence suggests that there is no significant difference between treatment with tetracyclines or clindamycin plus rifampicin in validated outcomes after 12 weeks, regardless of disease severity, so tetracyclines should be the first‐line treatment in moderate‐to‐severe disease 8 .…”