FEATURE ARTICLE MechanisticInsightsIntoToday’s Hours … · Current consensus is that mild...

FEATURE ARTICLE

Mechanistic Insights IntoToday’s(andTomorrow’s) Treatments forModerate-to-Severe Psoriasis

Melodie S. Young, Kristine J. Kucera

ABSTRACT: Psoriasis is a chronic immune-mediated dis-ease, and several cytokine pathways in the psoriaticcascade have been identified and investigated asclinical targets for systemic therapy. This review providesan overview of psoriasis, including discussion of clinicalvariants, environmental and genetic risk factors, knowncomorbidities, treatment strategies, and limitations inevaluating disease severity. The manuscript then focuseson addressing how existing biologics target the variouspathways described in the pathogenesis of psoriasis, how

modulating these mechanisms can improve outcomesover time, and how new insights have led to the de-velopment of agents that can target different pathwaysassociatedwith the disease. Overall, biologics that targettumor necrosis factor-! or interleukin-12/23 have estab-lished themselves as effective, well-tolerated treatmentoptions for chronic plaque psoriasis that can quicklyproduce dramatic clinical improvement. Unlike topical,phototherapy, and conventional systemic therapies thatdo not specifically target the underlying pathogenesis ofpsoriasis, biologics have been, and continue to be, de-veloped based on identifying therapeutic targets withinthe immune and inflammatory pathways associatedwith disease development and progression. Recently,interleukin-17A has been identified as a central cytokinedriver in the pathogenesis of psoriasis, and biologic ther-apy targeting this cytokine has recently been approved.Key words: Biologics, Pathogenesis, Psoriasis, Severity,Treatment

Psoriasis is a systemic inflammatory diseasethat affects innate and adaptive immune path-ways (Chiricozzi & Krueger, 2013; Girolomoni,Mrowietz, & Paul, 2012). Although the etiol-ogy of psoriasis is complex and remains largely

unknown, it has become clear over the past several yearsthat psoriasis goes beyond the skin. To effectively target theunderlying disease pathogenesis, drugs are needed that actsystemically on specific molecular components of the im-mune system (Baker et al., 2013; Girolomoni et al., 2012;Sivamani et al., 2013). As understanding of the psoriaticdisease process has improved, several biologic agents havebecome available that inhibit select cytokines associatedwith psoriatic plaque formation (e.g., antitumor necrosisfactor-! [TNF!]Vetanercept, adalimumab, infliximab;interleukin [IL]-12 and IL-23 inhibitorVustekinumab;and IL-17A inhibitorVsecukinumab; Sivamani et al., 2013).Apremilast, a small-molecule inhibitor of phosphodiesterase-4,

2.5 Contact

Hours

VOLUME 8 | NUMBER 1 | JANUARY/FEBRUARY 2016 29

Melodie S. Young, MSN, A/GNP-C, DCNP, Modern DermatologyYABaylor Health Texas Affiliate, Graduate School of Nursing, TheUniversity of Texas at Arlington, Arlington, and Modern ResearchAssociates, Dallas, TX.Kristine J. Kucera, PA-C, MPAS, DHS, Dermatology Center of Frisco,Frisco; UT Southwestern Medical Center, Dallas; and UNT HealthScience Center, Ft. Worth, TX.

Technical assistance with editing and styling of the manuscript forsubmission was provided by Oxford PharmaGenesis, Inc., and wasfunded byNovartis Pharmaceuticals Corporation. The authors werefully responsible for all content and editorial decisions and receivedno financial support or other form of compensation related to thedevelopment of this manuscript. The opinions expressed in the man-uscript are those of the authors, and Novartis Pharmaceuticals hadno influence on the contents.Melodie S. Young is a speaker or consultant for AbbVie, Celgene,Janssen, and Lilly and a clinical investigator for Amgen, Janssen,Novartis, Merck, Celgene, Pfizer, Galderma, and Eli Lilly. Kristine J.Kucera is a speakeror advisor forAbbVie, Actavis, Amgen, Aqua, Bayer,Innocutis, Janssen, Novartis, Promius, and Valeant and a consultantfor Eli Lilly.This is an open-access article distributed under the terms of theCreative Commons Attribution-Non Commercial-No DerivativesLicense 4.0 (CCBY-NC-ND), where it is permissible to downloadand share the work provided it is properly cited. The work cannot bechanged in any way or used commercially.

Correspondence concerning this article should be addressed toMelodie S. Young, MSN, A/GNP-C, DCNP, Modern ResearchAssociates, 9101NCentral Expressway, Suite 170,Dallas, TX75205.E-mail: [email protected]

DOI: 10.1097/JDN.0000000000000186

Copyright © 2016 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited.

is also available (Schafer, 2012). In addition, several othersmall molecules are being investigated that inhibit a varietyof kinases (in particular, Janus kinase and protein kinase C;Ortiz-IbaDez, Alsina,&MuDoz-Santos, 2013; Schafer, 2012).Improvements in our understanding of psoriasis have sub-sequently led to the development of newer agents that maytarget themechanism of disease more explicitly. Specifically,IL-17A has been identified as a central cytokine driver in thepathogenesis of psoriasis, and biologic agents targeting thiscytokine are currently in late-stage clinical development(ixekizumab) or have been recently approved (secukinumab;Cai et al., 2011; Chiricozzi et al., 2011; Krueger et al.,2012; Langley et al., 2014; Leonardi et al., 2012).

This article reviews how existing biologics target knownmechanisms of disease in psoriasis and how modulatingthese mechanisms can improve outcomes over time. It alsopresents new insights into the pathophysiology of psori-asis that have led to the development of additional agentsthat target specific pathways associated with the disease.

PSORIASIS: AN OVERVIEWPsoriasis is a common immune-mediated disorder affect-ing an estimated 2%Y3% of the population worldwide(National Psoriasis Foundation [NPF], n.d.-b). Psoriasisis a heterogeneous disease, both in terms of clinical pre-

sentation and risk factors. Table 1 provides a descriptionof the variants of psoriasis, including the frequency andmost common characteristics of each phenotype (Ladizinskiet al., 2013; VillaseDor-Park et al., 2012). By far, the mostcommon variant of psoriasis is plaque psoriasis, which ischaracterized by red, scaly plaques that typically appearon the scalp, elbows, knees, and trunk (Ladizinski et al.,2013). In addition to the skin lesions associated with pso-riasis, an estimated 50% of psoriatic patients have finger-nail involvement, and 35% have toenail involvement(Menter et al., 2008); nail changes may include pitting,oil spots, leukonychia, subungual hyperkeratosis, dystro-phy, and onycholysis (Ladizinski et al., 2013; VillaseDor-Park et al., 2012). Psoriasis is also linked with a numberof comorbidities, including psoriatic arthritis, metabolicsyndrome (clustering of obesity, hypertension, dyslipidemia,and insulin resistance), Type 2 diabetes, and depression. Pso-riatic arthritis is an inflammatory spondyloarthropathy thatis estimated to affect anywhere from 6% to 42% of patientswith psoriasis (Gottlieb et al., 2008); its presentation issomewhat heterogeneous, but characteristic features ofteninclude asymmetric distal oligoarthritis, sausage-like digits(dactylitis), and enthesitis (Gottlieb et al., 2008). In addi-tion to the aforementioned comorbidities, patients withpsoriasis are at increased risk for cardiovascular disease

TABLE 1. Variants of Psoriasis

Variation Frequency Common Signs and Sites of Involvement

Chronicplaque psoriasis

Most common(980% of cases)

& Well-defined, erythematous plaques with adherent silvery scales

& Preferred involvement sites are the scalp, extensor surfaces of the elbowsand knees, and lower trunk

& Chronic course, with periods of remission

Intertriginouspsoriasis

Common & Thin, well-defined, shiny erythematous plaques with minimal scaling

& Preferred involvement sites are the various skin folds including the axillae,behind the ears, inframammary region, and lower trunk

Pustular psoriasis Uncommon & Eruption of sterile pustules; multiple patterns of pustule formation exist

& Preferred involvement sites depend on pattern type

Erythrodermicpsoriasis

Rare & Generalized erythema and scaling; may affect more than 75% of bodysurface area

& Hair loss and nail dystrophy may also be seen; patient may exhibit systemicsymptoms such as fever, chills, and fatigue

& May be acute or chronic

& Potentially life threatening

Guttate psoriasis Rare & Pink, oval (drop-shaped) papules with silvery scaling

& Preferred involvement sites of the trunk and extremities

& May be acute or chronic

& Occurs in younger patients; many progress to chronic plaque psoriasis

& Often develops post-strep throat

Ladizinski et al., 2013; VillaseDor-Park, Wheeler, & Grandinetti, 2012.

30 Journal of the Dermatology Nurses’ Association


including myocardial infarction, stroke, vascular inflamma-tion, and atherosclerotic disease (Baker et al., 2013; Gelfand&Yeung, 2012; Kimball et al., 2008). Interestingly, it hasbeen observed that patients’ risk for developing many ofthese comorbidities is independent of traditional cardiovas-cular risk factors, especially for thosewithmoderate-to-severedisease. This reinforces the notion that psoriasis is a sys-temic disorder affecting more than just the skin, requir-ing a systemic approach to care (Gelfand & Yeung, 2012;Kimball et al., 2008).

Several genetic factors are strongly linked to psoriasis.Ten chromosomal regions (designated PSORS1YPSORS10)have been identified as being significantly associated withpsoriasis, and many of the genes linked to psoriasis arealso known to regulate specific inflammatory pathways.Overall, it is estimated that individuals with a first-degreerelative affected by psoriasis are four to six times morelikely to develop psoriasis compared with the generalpopulation (Girolomoni et al., 2012). In individuals witha genetic predisposition for psoriasis, many differentenvironmental triggers have been associated with precip-itating the onset or worsening of psoriasis, including in-fection (e.g., streptococcal), skin trauma, use of certainprescription drugs (e.g., lithium, antimalarials, beta blockers,interferon), alcohol consumption, cigarette smoking, stress,excessive exposure to ultraviolet radiation (sunburn), andautoimmune disorders (e.g., vitiligo, celiac disease, thyroiddisease; Mallbris et al., 2005; NPF, 2013; VillaseDor-Parket al., 2012; Wheeler, 2010).

Current consensus is that mild psoriasis can be success-fully treated with topical agents, whereas phototherapy orsystemic or biologic therapy is indicated for moderate-to-severe disease (Baker et al., 2013; Mrowietz et al., 2011).However, psoriasis at any level can have a significantnegative impact on overall quality of life (e.g., even whenonly a small portion of body surface area [BSA] is affected),thereby challenging the label of ‘‘mild’’ disease. Results ofa population-based survey on the burden of psoriasis es-timate that, of the more than 4.5 million adults diagnosedwith psoriasis in the United States, 2.6 million (È60%)have little or no skin involvement, yet more than 1 millionpatients are substantially dissatisfied with their treatment,and roughly half a million Americans report that psoriasisis a major problem in their everyday life (Stern, Nijsten,Feldman, Margolis, & Rolstad, 2004). An estimated 80%(È800,000) of those who report being very dissatisfiedwith treatment and more than 60% (È300,000) of thosewho report psoriasis is a major problem have psoriasiscovering a BSA of less than 10% or 10 palms (Stern et al.,2004). Findings such as these highlight the limitations ofcurrent definitions used for diagnosis of mild versus mod-erate versus severe psoriasis.

European and Australian consensus guidelines for as-sessing the severity of psoriasis rely heavily on the use ofPsoriasis Area and Severity Index (PASI) and DermatologyLifeQuality Index (DLQI) scores, definingmild psoriasis as

PASI e 10 andDLQI e 10 andmoderate-to-severe psoriasisas PASI 9 10 andDLQI 9 10 (Baker et al., 2013; Mrowietzet al., 2011). In addition to the PASI and DLQI requirements,European consensus guidelines also include BSA e 10%asa criterion for mild psoriasis and BSA 9 10% as a criterionfor moderate-to-severe psoriasis (Mrowietz et al., 2011).Although PASI and DLQI are generally considered to berigorous, objective assessments of disease severity, clinicalconsensus from the NPF acknowledges that these classifi-cation instruments are often not practical for use in every-day clinical settings (Pariser et al., 2007). TheNPF consensusstates that disease severity is generally a subjective assess-ment based on the practitioner’s estimation of BSA affectedas well as disease location, lesion thickness, physical symp-toms, and emotional and financial burdens of psoriasis onthe patient’s quality of life (Pariser et al., 2007). In studiesconducted by theNPF, psoriasis is classified asmoderate ifthere is as little as 3% BSA affected (Horn et al., 2007)and as moderate to severe if there is at least 5% BSA in-volvement (Pariser et al., 2007). However, in cases wherepsoriasis affects even small areas in visible or sensitive lo-cations, such as the face, scalp, genitals, nails, and palms orsoles, it is often appropriate to classify psoriasis covering aBSA G 5% as moderate to severe. Other sensitive areas thatshould be considered in psoriasis classification include theeyelids, lips, mouth, and skin folds (NPF, 2008). In addition,regardless of BSA affected, all cases of erythrodermic, pus-tular, and guttate psoriasis should be classified as moderateto severe and treated with systemic therapy and/or photo-therapy (Pariser et al., 2007).

Other factors to consider when determining the sever-ity of psoriasis include the burdens associated with symp-toms of pain, itching, burning, stinging, and bleeding inaffected areas (Baker et al., 2013; Bilac, Ermertcan, Bilac,Deveci, &Horasan, 2009). A recent study that examinedthe etiopathogenesis and burdens of these symptoms foundthat they are frequently associated with reduced quality oflife, affecting mood, sleep, concentration, sexual desire,and appetite (Bilac et al., 2009). In a cross-sectional study,42% of patients with psoriasis reported skin pain (pri-marily of moderate intensity), with sleep being the mostseverely affected function (Ljosaa et al., 2010). Severeitching can be particularly bothersome for patients, andscratching pruritic lesions can lead to excoriation, whichcan worsen or Koebnerize the lesions (Baker et al., 2013).In such cases, psoriasis defined as mild based on BSAshould be reclassified as moderate to severe (Baker et al.,2013). Overall, it is important for dermatology practi-tioners to be aware of the frequency of these symptomsand the negative impact they can have on patients andtheir caregivers and personal relationships when deter-mining psoriasis severity.

Because psoriasis is such a visually apparent disease, itcan cause patients to feel embarrassed, stigmatized,stressed, and depressed. It can also negatively affect bodyimage, personal relationships, intimacy, and employment



(Kimball, Jacobson, Weiss, Vreeland, & Wu, 2005;Schmitt & Ford, 2006; Young, 2005). As discussed, thepsychological impact of psoriasis does not always corre-late with disease severity based on BSA involvement (Kimballet al., 2005; Schmitt & Ford, 2006). Even small amountsof psoriasis can greatly affect patients; therefore, it iscritical for practitioners to evaluate each patient for uniqueemotional burdens when recommending treatment strat-egies, recognizing that aggressive therapies may be ap-propriate even with limited disease. Studies have shownthat women and younger patients (G40 years old) may beespecially vulnerable to the social stigma associated withpsoriasis and prone to depression (NPF, 2013; Wheeler,2010). In addition to feeling heightened social stigma,teenage patients may also be sensitive about their need forphysical privacy and independence. They may be reluc-tant to show practitioners the full extent of their disease orto ask a parent for help with medication (e.g., applying atopical treatment to a hard-to-reach area;Wheeler, 2010).

CURRENT TREATMENTS AND FUTURE DIRECTIONSTable 2 presents an overview of available treatments forpsoriasis (Cosentyx [secukinumab] injection prescribinginformation, 2015; Dovonex [calcipotriene] cream pre-scribing information, 2009; Ladizinski et al., prescribinginformation, 2013; NPF prescribing information, n.d.-a;Otezla [apremilast] tablets prescribing information, 2014;Tazorac [tazarotene] cream prescribing information,2011; Vectical [calcitriol] ointment prescribing informa-tion, 2012; Zithranol-RR [anthralin] cream prescribinginformation, 2009). Topical agents, including corticoste-roids, Vitamin D analogs, retinoids, coal tar preparations,and keratolytics, are only recommended for the manage-ment of mild, localized psoriasis (Mrowietz et al., 2011;Pariser et al., 2007). Topical agents cannot effectively con-trol moderate-to-severe psoriasis and do not target the un-derlying disease process (Ladizinski et al., 2013; Mrowietzet al., 2011; Poulin et al., 2012). Patient satisfaction withtopical agents is generally low because of their limitedefficacy and inconvenient administration (Poulin et al., 2012),and topical preparations can be greasy,messy, malodorous,and time-consuming to apply. Certain agents (e.g., coaltars) can also stain skin and clothing (Ladizinski et al., 2013).

To significantly clear skin symptoms and improve pa-tients’ quality of life, it is recommended that patients withmoderate-to-severe psoriasis receive systemic therapy withFood and Drug Administration-approved conventionalagents (e.g., methotrexate, cyclosporine) or biologic agents(e.g., secukinumab, infliximab, adalimumab, etanercept,ustekinumab;Mrowietz et al., 2011). In addition, the newsmall-molecule apremilast should also be considered as itis approved for adults with moderate-to-severe plaque-type psoriasis. The American Academy of Dermatologyreleased a position statement in 2013 stating that ‘‘psoriasispatients with moderate-to-severe psoriasis and, thus, can-didates for systemic therapy, should be placed on the

appropriate therapy from the beginning, i.e., photother-apy, or systemic therapy including biologic therapy’’(American Academy of Dermatology and AAD Associ-ation, 2013). However, despite consensus guidelines issuedby the NPF (Pariser et al., 2007) and expert panels from19European countries (Mrowietz et al., 2011) and acrossAustralia (Baker et al., 2013) recommending the use ofsystemic therapy (possibly in combination with photo-therapy) for the treatment of moderate-to-severe psoria-sis, many dermatology practitioners are still reluctant touse systemic agents as first-line therapy or to switch to sys-temic agents when topical agents are ineffective (Mrowietzet al., 2011). For example, a study by Horn and colleaguesthat surveyed 1657 patients with moderate (BSA of 3%Y10%) or severe (BSA 9 10%) psoriasis from 2003 to 2005found that, among those who were receiving any treat-ment for their psoriasis, most patients with moderatepsoriasis (73%) or severe psoriasis (57%) were receivingonly topical therapy (Horn et al., 2007). More recently,Armstrong, Robertson,Wu, Schupp, and Lebwohl (2013)confirmed that undertreatment of moderate-to-severe pso-riasis was still problematic in surveys conducted through2011. In their survey of 5604 patients with psoriasis orpsoriatic arthritis, these authors found that, in 2011, 23.6%of patients with moderate disease and 9.4% of patients withsevere disease were receiving no treatment, and 29.5% and21.5% (51% combined), respectively, were receiving onlytopical therapy (Armstrong et al., 2013). Furthermore, inthis population with high rates of psoriasis undertreatment,most (52%) of survey respondents were dissatisfied withtheir treatment (Armstrong et al., 2013). More concerningis the limited success of topical treatments beyond milddisease, yet they continue to be the first-line therapy inpractice and have no known therapeutic benefit for man-aging comorbidities such as psoriatic arthritis. In contrast,a 2012 study that evaluated patient satisfaction by class oftherapy for moderate-to-severe psoriasis found that most(63%) of the patients treated with biologics were ‘‘verysatisfied’’ with their treatment (Poulin et al., 2012). Takentogether, the above survey findings highlight the need toincrease education and advocacy about systemic agentsand treatment goals to ensure that patients are appro-priately treated and have realistic expectations regardingthe benefits and risks of such therapy.

The decision to treat patientswith conventional systemicagents or biologics should be based on individualizedneeds, convenience, and safety and efficacy considerationsof a particular agent. For many patients, conventional sys-temic agents are contraindicated, or their use is limitedby common or potentially serious side effects (Table 2).Methotrexate is associated with numerous drug interac-tions and contraindicated in patients with elevated liverenzymes or a history of alcohol abuse, liver disease, orbone marrow hyperplasia. It is also a concern for patientsof reproductive age. Side effects of methotrexate includenausea, vomiting, anorexia, stomatitis, macrocytic anemia,



TABLE

2.Curren

tTrea

tmen

tsforPsoriasis

Drug

Brand

Name

ModeofA

ctio

nDosa

ge/A

dministra

tion

Contraindicatio

nsSideEffects

Comments

Topicals

Anthralin

Zithranol-R

R(Elorac)

Antip

roliferativ

eand

anti-infla

mmatory

effects

onskin

1.2%

cream

applie

donc

edaily

for5

Y30minutes

and

thenremove

dbywashing

Acuteora

ctiv

ely

infla

medpso

riatic

eruptio

ns

Skin

irrita

tion,

stainingofh

air,

anduna

ffectedskin

Messy,

time

consumingto

apply

andrin

se

Calcipotriene

Dovo

nex(Leo)

Synthetic

Vita

min

D3

analog;slo

wsskin

cellgrowth,fla

ttens

lesio

ns,remove

ssc

ale

0.00

5%cream

or

scalp

solutio

napplie

dto

affectedarea

twicedaily

Hyp

ercalcemia,

Vita

min

Dtoxicity

Skin

irrita

tion,d

ryskin,p

eeling,rash,

derm

atitis,

worsening

ofp

soria

sis

Notforu

seon

theface

Calcitriol

Vectic

al

(Galderm

a)

Naturally

occurring

activ

eform

of

Vita

min

D3;controls

exc

essiveskin

cellproductio

n

Applie

dto

affected

areatw

icedaily;

maximum

dose

,20

0g/w

eek

None

Hyp

ercalciuria

,pruritus,

cha

ngesin

calcium

metabolism

Notforu

seonthe

face,lips,ore

yes

Taza

rotene

Tazo

rac

(Alle

rgan)

Vita

min

Aderiv

ativ

e(retin

oid);thoughtto

slow

skin

growth

Applie

dto

affected

areaoncedaily,

intheeve

ning,to

cove

rlesio

nswith

athin

film

Pregnanc

y(m

ay

cause

fetalh

arm

)Skin

irrita

tion,d

ryskin,susceptib

ility

tosunburn

Canbeuse

don

theface,h

airline,

scalp,a

ndnails

Womenof

childbearin

gage

mustuserelia

ble

birthcontrold

urin

gtreatm

ent

Corticosteroids(e

.g.,

clob

etasol,fluoc

inon

ide,

deso

ximetaso

ne,

hydrocortiso

ne,

flutic

aso

ne,o

thers)

Manybrands/

potencies

Anti-infla

mmatory

propertiesreduce

swellin

gand

redness

oflesio

ns

Varyingstreng

thsand

form

ulatio

nsava

ilable;

gene

rally

applie

donceortwicedaily

None

Skin

thinning,p

igmentatio

nchanges,easy

bruising,

stretchmarks,redness,

dila

tedsurfa

ceblood

vessels,

acne

Notforu

seon

faceoro

ther

sensitiveareasfor

long

perio

ds

Canlose

efficacy

ove

rtim

e;a

brupt

disc

ontin

uatio

ncan

cause

flares

Pulse

dosin

gcan

minim

izeriskof

sideeffects

(continues)



TABLE

2.Curren

tTrea

tmen

tsforPsoriasis,Continued

Drug

Brand

Name

ModeofA

ctio

nDos

age/

Administra

tion

Contraindicatio

nsSideEffects

Comments

Salic

ylic

acid

Many

gene

ricOTC

form

ulatio

nsKe

ratolytic

;acts

asasc

ale

lifterto

softenand

remove

pso

riasis

scales

Applie

dasneeded

inconcentratio

ns

upto

3%(creams,

gels,

ointm

ents,

shampoos,so

ap)

None

Skin

irrita

tion

Byremovingsc

ales,

salic

ylic

acid

may

allo

wothertopical

agentsto

better

pene

trate

theskin

Coaltar

Many

gene

ricOTC

form

ulatio

nsCanslo

wskin

growth

andrestore

norm

ala

ppearanc

e

Canbeapplie

ddire

ctly

ora

ddedto

bath

water;gene

rally

leftonskin

forQ

2ho

urs

None

Skin

irrita

tion,redness,

and

dryness;increase

dse

nsitivity

tosunburn

Messy,

strongodor,

stains,ve

rytim

e-consuming

Knowncarcinogenat

highconcentratio

ns

Conv

entiona

lsystemic

therapies

Cyc

losp

orin

eNeoral

(Nova

rtis)

and

others

Immunosuppressant;

slowsgrowth

of

skin

cells

Usually

take

norally

twicedaily

ata

startingdose

of

2.5mg/kg/d

ay

Compromise

dim

munesystem,

activ

ese

rious

infectio

ns,abnorm

al

kidneyfunctio

n,un

controlla

ble

hypertension,c

ancer

orh

istory

ofc

anc

er

(otherthancertain

skin

cancers),se

vere

gout,radiatio

ntherapy,

pregnancy

Decrease

drena

lfunctio

n,hy

pertension,e

leva

ted

cho

lesterola

nd/o

rtriglycerid

es,exc

essive

hairgrowth,tinglingor

burningin

thearm

sorlegs,

skin

sensitivity,swellin

gor

growth

ofg

um

tissue,flu-like

symptoms,upse

tstomach,

fatig

ue,m

usc

leorjointp

ain,

neurologic

symptoms

(e.g.,headache

,tremor)

Increase

driskof

skin

canc

erin

patie

ntstreated

with

PUVA,

methotrexa

te,

oro

ther

immunosuppressants

ManydrugYd

rug

reactio

ns(e.g.,antib

iotic

s,anti-infla

mmatory

agents,antifungals,

calcium

channe

lblocke

rs,a

nticonv

ulsants)

Improve

mentcanoccur

with

in2weeks;c

omplete

resp

onse

maytake

3Y4months

(continues)



TABLE

2.Curren

tTrea

tmen


Drug

Brand

Name

ModeofA

ctio

nDosa

ge/A

dministra

tion

Contraindicatio

nsSideEffects

Comments

Methotrexa

teUsually

sold

as

ageneric

form

ulatio

n

Antim

etabolite;

slowsthe

rate

of

skin

cellgrowth

Usually

take

norally

onc

eaweek;injectable

form

ulatio

nsava

ilable

Alcoholism,a

lcoho

licoro

therc

hronic

liver

dise

ase,immun

odefic

ienc

ysyndromes,womenor

theirpartne

rsplann

ing

pregna

ncy,

activ

epeptic

ulcers,signific

ant

kidne

yorlivera

bno

rmalities,

activ

einfectio

usdise

ase,

hematologic

diso

rders

Nause

a,fatig

ue,

difficulty

sleeping,

lighthe

adedne

ss,

mouth

ulcers,v

omiting,

headache,e

asy

bruisingandbleeding,

feve

r,diarrh

eawith

bloodystools,

chills,

sensitivity

tosunlight,

burningse

nsa

tionin

lesio

ns,hairloss,

liverfibrosis

Regularb

loodtests

neededto

checkforside

effectsontheliver,blood,

orb

onemarro

w

Womenshould

wait

Q4monthsafter

stoppingtreatm

ent

before

becoming

pregnant;menshould

waitQ3monthsbefore

acouple

triesto

conc

eive

Folic

acid

canreducerisk

ofsideeffects

Improve

mentc

anoccur

with

in3Y

6weeks;c

omplete

resp

onse

maytake

6months

Acitretin

Soria

tane

(Stie

fel)

Oralretin

oid;

exa

ct

mecha

nism

unkn

own;

retinoidsregulate

cellbeha

vior,

includingrate

ofskincell

growth

and

shedding

Take

norally

once

daily

with

food

(ava

ilable

in10

-,17

.5-,

and25

-mgdose

s)

Pregna

ncy,

breastfeeding,

seve

relivero

rkidney

dise

ase

,uncontrolle

dhyp

erlipidemia

Hairloss,c

happedlip

s,dry

mouth,

dry

skin

and

eye

s,bleedinggums,

nose

bleeds,se

nsitivity

tosunlight,peeling

fingertips,nailchanges,

cha

ngesin

serum

lipids,depression,

aggressivethoughtsor

thoughtsofself-harm

,he

adache,jointpain,

decrease

dnightv

ision,

eleva

tedlivere

nzymes

Cancause

seve

rebirth

defects;w

omenmust

useQ2birthcontrol

methods,should

not

becomepregnant

for3

yearsafter

disc

ontin

uatio

n

Should

notdonate

bloodfor3

years

afterd

iscontin

uatio

nWomenmustavo

idalcohold

uringtreatm

ent

andfor2

months

afterd

iscontin

uatio

n

Improve

mentm

ay

beslo

w(8Y1

6weeks;

peakeffectafter6

months)

(continues)



TABLE

2.Curren

tTrea

tmen


Drug

Brand

Name

ModeofA

ctio

nDosa

ge/A

dministra

tion

Contraindicatio

nsSideEffects

Comments

Small-molecule

inhibito

rs

Apremila

stOtezla

(Celgene)

Oralsmall-molecule

inhibito

rof

pho

spho

diesterase-4

Titrate

torecommended

dose

of3

0mgtw

icedaily

Knownhyp

ersensitivity

toapremila

stora

nyexc

ipientsin

form

ulatio

n

Diarrh

ea,n

ause

a,

headache

,upper

resp

iratory

tract

infectio

n,v

omiting,

naso

pharyngitis,upper

abdominalp

ain

Inclinicaltria

ls,È30

%of

patie

ntsachieve

dPA

SI75

after1

6weeks

Biologics

Etanercept

Enbrel(Amgen)

Fusio

nprotein

of

TNF!

receptor

extracellular

domain

and

Fcportionof

humanIgG

SCinjectio

n50

mgtw

ice

weeklyfor3

months,then

maintenanc

edose

sonceweeklythereafter

Activ

ese

rious

infectio

n;

history

ofrecurrent

infectio

ns;history

of

heartfailure,m

ultiple

sclerosis,o

rother

demye

linatin

gdise

ase

Dizziness,sore

throat,

cough,stomach

pain,injectio

n-site

reactio

ns,up

per

resp

iratory

infectio

ns,

headache

,rhinitis

Sideeffectsare

generally

mild

and

maydecrease

ove

rtim

e

Inclinicaltria

ls,È49

%of

patie

ntsachieve

dPA

SI75

after3

months

Adalim

umab

Humira

(AbbVie)

Humanrecombinant

IgG

monoclonal

antib

odysp

ecific

forTNF!

SCinjectio

nof8

0mg

onDay1,

then40

mg

eve

ryotherw

eek

startingonDay8

Activ

ese

rious

infectio

n;

history

ofrecurrent

infectio

ns;history

of

heartfailure,m

ultiple

sclerosis,o

rother

demye

linatin

gdise

ase

Upperresp

iratory

tract

infectio

ns,a

bdominal

pain,h

eadache

,rash,

injectio

n-site

reactio

ns,

urin

ary

tractinfectio

ns

Sideeffectsare

generally

mild

and

maydecrease

ove

rtim

e

Inclinicaltria

ls,È70

%ofpatie

nts

achieve

dPA

SI75

after3months

Infliximab

Remicade

(Janssen)

Chimeric

monoclona

lIgG

antib

ody

targetin

gTN

F!

IVinfusio

nof5

mg/kg;

threeinfusio

nsduring

thefirst6weeks,then

onceeve

ry8weeks

Activ

ese

rious

infectio

n;h

istory

ofrecurre

nt

infectio

ns;history

ofh

eartfailure,

multip

lesclerosis,o

rotherd

emye

linating

dise

ase

Infusio

nreactio

ns,

upperresp

iratory

tractinfectio

ns,

headache

,rash,

coug

h,stom

ach

pain

Sideeffe

ctsare

gene

rally

mild

and

maydecrease

ove

rtim

e

Inclinicaltria

ls,È80

%ofp

atie

ntsachieve

dPA

SI75

after1

0weeks

(continues)



phototoxicity, seizures, hepatotoxicity, renal failure, bonemarrow suppression, and pulmonary fibrosis (Aaronson& Lebwohl, 2004; Christophers, Griffiths, Gaitanis, &van de Kerkhof, 2006). In addition, methotrexate hasmore black box warnings than any other therapy forpsoriasis. Cyclosporine is contraindicated in patients withelevated creatinine levels or a history of hypertension, renaldisease, gout, or hyperuricemia. Side effects of cyclosporineinclude nephrotoxicity, hypertension, hyperlipidemia,hypomagnesemia, hyperkalemia, and increased susceptibilityto infection and malignancy (Aaronson & Lebwohl, 2004;Christophers et al., 2006). Retinoids are highly teratogenicand can cause hair loss, dry skin or lips, cheilitis, dermatitis,increased serum lipids and liver enzymes, and osteoporosis(Aaronson & Lebwohl, 2004). Given the long lists of safetyconcerns associated with conventional systemic agents, itis not surprising that a survey of 301 patients with pso-riasis treated at European outpatient clinics found thatmore than 90% of patients had comorbidities that couldpreclude the use of conventional systemics (most commonly,hypertension, abnormal liver enzymes, and hyperlipidemia;Christophers et al., 2006).

The biologic agents approved for the treatment ofmoderate-to-severe psoriasis are all comparably safe andwell tolerated; however, cases of serious infection havebeen observed with these agents, and they may increaserisk of malignancy (Cosentyx [secukinumab] injectionprescribing information, 2015; Enbrel [etanercept] solutionprescribing information, 2015; Humira [adalimumab]injection prescribing information, 2014; Remicade[infliximab] lyophilized concentrate for injection pre-scribing information, 2015; Stelara [ustekinumab] injectionprescribing information, 2014). Recent studies suggestthat the increased risks for infection and malignancy aresmall and may not be statistically significant (Dommaschet al., 2011), but many practitioners choose to avoid usingbiologics in patients with a history of malignancy or withactive or frequent infections. All patients who are candi-dates for biologic therapy should be screened for tuber-culosis, Hepatitis B and C and other serious infections,nonmelanoma skin cancer, and othermalignancies (Ortleb& Levitt, 2012; Sivamani et al., 2013).

Although data are limited on the comparative efficacyof conventional systemics versus biologics (Lee et al., 2012),two randomized controlled trials published to date showedthat adalimumab (Saurat et al., 2008) and infliximab(Barker et al., 2011) were associated with significantlyhigher PASI 75% improvement (PASI 75) responses com-pared with methotrexate. Furthermore, a network meta-analysis of data from 20 randomized controlled trials ofapproved biologic agents for the treatment of moderate-to-severe psoriasis showed that 52%of patients treatedwithetanercept, 59% treated with adalimumab, 69%Y75%treated with ustekinumab, and 80% treated with infliximabachieved PASI 75 responses with a standard course oftherapy (Reich, Burden, Eaton, & Hawkins, 2012).

TABLE

2.Curren

tTrea

tmen


Drug

Brand

Name

ModeofA

ctio

nDosa

ge/A

dministra

tion

Contraindicatio

nsSideEffects

Comments

Secuk

inum

ab

Cose

ntyx

(Nova

rtis)

Humanmonoclona

lantib

odytargetin

gIL-17A

SCinjectio

nof3

00mg

atW

eeks

0,1,

2,3,

and

4,thenonce

eve

ry4weeks

Cautio

nshould

be

used

whe

nco

nsidering

usein

patie

ntswith

chronicinfectio

nora

history

ofrecurrent

infectio

nand

inpatie

ntswith

active

Crohn’sdise

ase

Naso

pha

ryng

itis,

diarrh

ea,a

nd

upperresp

iratory

tractinfectio

n

Inclinicaltria

ls,È80

%ofp

atie

ntsachieve

dPA

SI75

after1

2weeks,a

ndÈ67

%ofp

atie

ntsachieve

dIG

Aofc

learo

ralm

ostclear

Ustekinumab

Stelara

(Janssen)

Humanmonoclona

lantib

odytargetin

gthep40

subunit

ofIL-12

andIL-23

SCinjectio

nsatW

eeks

0and

4,theneve

ry12

weeks

of4

5mgifweighte

220lbs

or9

0mgifweight

922

0lbs

Activ

einfectio

ns,

history

of

recurrent

infectio

ns

Upperresp

iratory

infections,h

eadach

e,fatig

ue,redness

atinjectio

nsite,

backpain

Inclinicaltria

ls,È67

%ofp

atie

ntsachieve

dPA

SI75

after1

2weeks

None

ofthe

agentsa

reapprove

dforu

seinchildrenwith

psoria

sis(C

osentyx

[secuk

inum

ab]injectio

nprescrib

inginform

atio

n,20

15;D

ovo

nex[calcipotriene

]cream

prescrib

inginform

atio

n,20

09;Ladizinskieta

l.,presc

ribinginform

atio

n,20

13;N

PF,p

resc

ribinginform

atio

n,n.d.-a

;Otezla

[apremila

st]tabletspresc

ribinginform

atio

n,2

014;

Tazo

rac[taza

rotene

]cream

presc

ribinginform

atio

n,20

11;V

ectic

al[calcitriol]

ointm

entp

resc

ribinginform

atio

n,2

012;

Zithranol-R

R[a

nthralin]cream

presc

ribinginform

atio

n,2

009).IGA

=inve

stigator’sglobala

ssessment;IL=interle

ukin;IV=intrave

nous;OTC

=ove

r-the-counte

r;PA

SI=Psoria

sisAreaandSe

verityIndex;

PUVA

=pso

ralenplusultravioletlig

ht;RR=rapid

release

;SC

=su

bcuta

neous;TN

F=tumorn

ecrosisfa

cto

r.



Overall, many experts believe that, over the last 10 years,biologic agents have revolutionized the treatment ofmoderate-to-severe psoriasis because available biologics target cyto-kines that regulate the immune system and control theunderlying pathogenesis of psoriasis (Sivamani et al., 2013).As further improvements have been made in the under-standing of psoriasis, new cytokines have been identifiedas potential targets for drug development (Chiricozzi &Krueger, 2013). Drugs designed to address these and futuretargets may provide new solutions for disease managementand have the potential to positively impact the patientexperience. The next section will review the immunologyof psoriasis, highlighting how existing biologics functionand how new biologics in development target key inflam-matory pathways associated with psoriatic activity.

PSORIASIS IMMUNOLOGY AND THE RATIONALE FORTODAY’S (AND TOMORROW’S) BIOLOGICSImmune responses in the skin provide critical defenseagainst microbial pathogens and chemical and physicalinsults; however, when skin immune responses are excessive,chronic inflammation can result, such as that observed inpsoriasis (Nestle, Di Meglio, Qin, & Nickoloff, 2009).Figure 1 presents a model of psoriasis immunopathogenesisillustrating that, in genetically predisposed individuals,environmental factors andother triggers can initiate psoriasisby instigating the production of multiple cytokines asso-ciated with plaque formation (Lynde, Poulin, Vender,Bourcier, & Khalil, 2014; Nestle et al., 2009). Specifically,stressed keratinocytes trigger production of IL-1", IL-6, andTNF!, and keratinocyte self-DNA forms complexes with

FIGURE 1. Psoriasis immunopathogenesis. Reprinted with permission from Macmillan Publishers Ltd. (Nestle et al., 2009).



antimicrobial peptides to activate plasmacytoid dendriticcells to produce interferon-!. In turn, these cytokines that areproduced in response to stimulus activate dermal dendriticcells (Lynde et al., 2014; Nestle et al., 2009). In addition,other unknown factors may activate dendritic cells, whichmay explain observed psoriatic plaque formation in theabsence of a defined stimulus (Nickoloff & Nestle, 2004).

Activated dendritic cells in the dermis secrete IL-12 andIL-23, which promote differentiation and proliferation ofnaiveTcells into helperT1 (TH1) and TH17 cells, respectively(Lynde et al., 2014; Nestle et al., 2009). When matured,TH17 cells secrete IL-17A, IL-17F, and IL-22, which stimu-late keratinocyte proliferation and release of antimicrobialpeptides, neutrophil-recruiting chemokines, and growthfactors, thus promoting progression of psoriatic plaqueformation and activation of additional dendritic cells andT cells. These events result in a self-reinforcing cascade or‘‘vicious cycle’’ of cytokine production and cell activation.

Cytokines targeted by available biologicsVTNF!, IL-12,IL-23, and IL-17AVare involved in many of the afore-mentioned processes (Lynde et al., 2014; Nestle et al.,2009; Nickoloff & Nestle, 2004). TNF!, as a broadlyacting cytokine mediator of inflammatory and immuneresponses, is secreted by a number of other cell types (e.g.,macrophages, mast cells, natural killer [NK] cells, andgranulocytes) and thus may be associated with the initialresponse to the events precipitating keratinocyte hyperpro-liferation and formation of psoriatic plaque as well as theinflammation associated with both psoriasis and psoriaticarthritis (Croft, Benedict, & Ware, 2013; Ware, 2013).TNF! is involved inmany pathways in the self-reinforcingcascade, and biologics targeting these cytokines are de-signed to disturb these processes and help restore skin toa more normal, nonpsoriatic state (Marble, Gordon, &Nickoloff, 2007; Yost & Gudjonsson, 2009).

IL-12 and IL-23 are also key cytokine mediators ofcellular immunity. Dendritic cells, macrophages, and kera-tinocytes produce IL-12 in response to microbial stimula-tion, which triggers induction of lymphokine-activatedkiller cells, activation of NK cells and T lymphocytes, anddifferentiation of naive T cells to TH1 cells (Benson et al.,2011; Torti & Feldman, 2007). Activated NK cells andTH1 cells then induce T-cell migration to the epidermisand stimulate keratinocyte proliferation (Torti & Feldman,2007). IL-23, together with other cytokines includingIL-1", IL-6, and transforming growth factor-", promotesdifferentiation of naive Tcells to TH17 cells (Benson et al.,2011; Damsker, Hansen, & Caspi, 2010). Continued IL-23signaling is also critical for survival and proliferation ofmature TH17 cells (Damsker et al., 2010). These TH17cells are central drivers of inflammation and immune re-sponses, and the IL-23/TH17 pathway is recognized as amajor immune pathway in the pathogenesis of psoriasis(Chiricozzi & Krueger, 2013; Damsker et al., 2010). Thebiologic agent ustekinumab binds to the common p40subunit of IL-12 and IL23, thereby blocking the down-

stream signaling of both cytokines in the psoriasis cas-cade and providing significant improvements in the clinicalsymptoms of psoriasis (Benson et al., 2011; Leonardi et al.,2008; Papp et al., 2008).

New psoriasis treatment strategies are focused on dis-rupting mechanistic pathways associated with the develop-ment or severity of immunologic responses occurring earlyin the sequence of events leading to plaque formation. Forexample, the recently Food and Drug Administration-approved phosphodiesterase-4 inhibitor (apremilast), onthe basis of its ability to potentially block the productionof proinflammatory cytokines (Schafer, 2012), and kinaseinhibitors (e.g., tofacitinib) are being investigated based onthe rationale that these small molecules will dampen thecellular responses to various cytokines produced in thiscascade (Ortiz-IbaDez et al., 2013). Apremilast acts upstreamin the psoriasis inflammatory cascade to decrease expressionof inducible nitric oxide synthase, TNF!, and IL-23, andit acts to increase expression of IL-10 (Schafer, 2012).Tofacitinib also targets initial immune responses by sup-pressing IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21 andinhibiting the differentiation of TH cells (TH1, TH2, andTH17; Ghoreschi et al., 2011; Ortiz-IbaDez et al., 2013).

Recent studies have highlighted IL-17A as a centraldriver of altered skin function in the pathogenic pathwaysof psoriasis and have made this cytokine an importantdownstream target for agents in development (Chiricozziet al., 2011; Chiricozzi & Krueger, 2013; Gaffen, 2011;Krueger et al., 2012). In addition to being a key productof TH17 cells, IL-17A is produced by neutrophils, mastcells, and cytotoxic T cells (TC17 cells), all of which arefound in excess in psoriatic lesions (Girolomoni et al.,2012; Res et al., 2010). Dermal ,& T cells are also foundin higher levels in psoriatic lesions compared with healthyskin; these proinflammatory cells produce IL-17A in re-sponse to IL-23 and/or IL-1" stimulation (Cai et al., 2011;Cai, Fleming, & Yan, 2013; Laggner et al., 2011).

Numerous roles of IL-17A have been identified in thepathogenesis of psoriasis: recruitment of myeloid dendriticcells and activated TH17 cells to psoriatic lesions, upregu-lation of neutrophil-chemoattracting chemokines on kera-tinocytes, stimulation of antimicrobial peptide expressionon keratinocytes, stimulation of IL-36 expression by kera-tinocytes, disruption of skin barriers, upregulation of IL-6production by fibroblasts and myeloid dendritic cells, up-regulation of IL-1 and IL-23, and chemokine (C-C motif)ligand 20 production by keratinocytes (Girolomoni et al.,2012; Marwaha, Leung, McMurchy, & Levings, 2012).In addition, synergistic action of IL-17A with TNF! hasbeen observed to promote TH17 cell-driven inflammation(Girolomoni et al., 2012; Marwaha et al., 2012).

There are several possible advantages of targeting IL-17Ainstead of more broadly acting upstream cytokines. Forexample, targeting IL-17A has the potential to reducepsoriatic skin inflammation while leaving other immunefunctions undisturbed (Girolomoni et al., 2012; Patel, Lee,



Kolbinger,&Antoni, 2013). In addition, because it is moreintrinsically involved in formation of the psoriatic plaque,targeting IL-17Amay result in fewer broad immune systemside effects (e.g., serious infection, malignancies) comparedwith blocking TNF! or IL-12 and IL-23 (Girolomoni et al.,2012). Further research will provide the necessary datato help clinicians determine if agents targeting IL-17Ahave a different safety profile from other biologics.

One biologic that targets IL-17 has been approved(secukinumab), and another is currently in clinical devel-opment (ixekizumab). Secukinumab is a human immu-noglobulin (Ig)G10 monoclonal antibody that selectivelybinds and neutralizes IL-17A (Hueber et al., 2010; Langleyet al., 2014). Ixekizumab is a humanized IgG4 monoclonalantibody that binds and neutralizes IL-17A (Krueger et al.,2012; Leonardi et al., 2012). Brodalumab is a fully humanmonoclonal antibody that binds to the receptor subunitIL-17RA, blocking all IL-17 family members that bind tothis receptor, including IL-17A, IL-17C, IL-17F, IL-17A/F,and IL-17E (IL-25). In clinical studies, patients treated withIL-17A inhibitors have experienced rapid and marked im-provements in psoriasis severity (Hueber et al., 2010;Krueger et al., 2012; Langley et al., 2014; Leonardi et al.,2012; Papp et al., 2013); for example, Figure 2 shows onepatient’s clinical response four weeks after receiving asingle infusion of secukinumab in a proof-of-concept study(Hueber et al., 2010). In a Phase 3 study of secukinumabin patients with moderate-to-severe psoriasis, significantimprovements in PASI scores were observed at Week 12compared with placebo and etanercept, and these im-

provements were maintained to 52 weeks (Langley et al.,2014). Interestingly, the clinical improvements observedin patients treated with IL-17A inhibitors correlate withhistological improvements and reduced gene expression(Chiricozzi & Krueger, 2013). In a Phase 2a study inpatients with moderate-to-severe plaque psoriasis, signif-icant PASI improvements observed four weeks after treat-ment with secukinumab were associated with reducedT-cell infiltration in skin lesions and reduced productionof inflammatory cytokines (Hueber et al., 2010). A Phase1 study of ixekizumab in patients withmoderate-to-severeplaque psoriasis also showed that keratinocyte prolifera-tion, hyperplasia, epidermal thickness, and keratinocyteexpression of innate defense peptides were reduced twoweeks after dosing, and normal histological skin appear-ance was achieved by Week 6 (Krueger et al., 2012).Overall, the investigational agents targeting IL-17A havebeen generally well tolerated in early-stage clinical studieswithout unexpected safety signals (Leonardi et al., 2012;Papp et al., 2013; Rich et al., 2013). However, larger-scale studies are underway to better establish the long-term safety profiles of these agents.

DISCUSSIONBiologics are effective, well-tolerated treatment options forchronic plaque psoriasis that can produce dramatic clinicalimprovements in a relatively short period (Sivamani et al.,2013; Wheeler, 2010). Unlike topical and conventionalsystemic therapies that were discovered serendipitously anddo not specifically address the underlying pathogenesis ofpsoriasis, biologics have been, and continue to be, developedbased on scientific evidence identifying therapeutic targetswithin the critical immune and inflammatory pathwaysassociatedwith the development and progression of disease(Nickoloff & Nestle, 2004). Furthermore, because biologicstarget underlying inflammation, earlier use of biologics mayslow disease progression and prevent inflammatory comor-bidities, such as atherosclerosis and metabolic syndrome(Golden, McCormick, & Ward, 2013).

When selecting appropriate psoriasis therapies, it is im-portant for practitioners to consider a variety of factorssuch as efficacy, onset of action, sustainability of efficacy,route of administration, convenience, safety, and tolera-bility. From a patient perspective, many have referred tobiologics as ‘‘wonder drugs’’ based on the high degree ofskin clearance, relatively few side effects, and convenientadministration (Wheeler, 2010). In addition, results of re-cent surveys evaluating patient experiences with psoriasistreatments have shown that satisfaction with biologics isnotably higher than with topicals or conventional systemictherapies (Callis Duffin et al., 2014; Poulin et al., 2012).Meta-analyses of data from randomized controlled trialsof available biologics have found that infliximab is themost effective TNF! inhibitor (in terms of mean PASI im-provement), and etanercept is the least effective, althoughthe clinical implications of these differences are unclear

FIGURE 2. Clinical response in a patient with chronic plaquepsoriasis after a single intravenous infusion of secukinumab3 mg/kg (Hueber et al., 2010). Reprinted with permission.



(Reich et al., 2012; Schmitt, Zhang, Wozel, Meurer, &Kirch, 2008). Comparative trials may also prove helpfulin choosing among the biologics; however, such studiesare limited to date. Of the few head-to-head trials,secukinumab and ustekinumab were found to be signifi-cantly more effective than etanercept over 12weeks of treat-ment (Griffiths et al., 2010; Langley et al., 2014). Theseefficacy differences may be explained, in part, by differ-ences in pharmacokinetic properties. Etanercept is clearedfrom serum roughly six times faster than adalimumab orinfliximab and has a shorter half-life (4 days for etanerceptcompared with 8Y10 days for infliximab, 10Y20 days foradalimumab, È21 days for ustekinumab, and È28 daysfor secukinumab; Baeten et al., 2010; Benson et al., 2011;Ware, 2013). Additionally, secukinumab was found to besignificantlymore effective than ustekinumab after 16weeksof treatment (Thaci et al., 2015).

In terms of safety, all available biologics are generallywell tolerated, and although biologics may increase pa-tients’ risk of serious infection andmalignancy, these eventsare rare (Dommasch et al., 2011). Infliximab is associatedwith the highest risk of neutralizing antibodies because itis a human-murine chimeric monoclonal anti-TNF anti-body, producing the risk for an infusion reaction or loss ofbenefit requiring a dose adjustment or other change. Incontrast, etanercept is a chimeric fusion of the human TNFreceptor with an antibody Fc fragment, and adalimumab,secukinumab, and ustekinumab are human IgG1 antibodies(Benson et al., 2011; Langley et al., 2014; Ware, 2013; Yost& Gudjonsson, 2009).

All available biologics, with the exception of infliximab,are administered subcutaneously, with initial dosing sched-ules ranging from twice weekly (etanercept) to once everyfour weeks (secukinumab and ustekinumab) with less fre-quent dosing over time for most agents (Langley et al.,2014; Sivamani et al., 2013). Infliximab is administeredby intravenous injection, as two initial injections twoweeksapart followed by dosing every 12 weeks (Sivamani et al.,2013). Survey results indicate that patients rate the con-venience of self-administered subcutaneous biologics higherthan intravenous infliximab (Callis Duffin et al., 2014).

Overall, it is important to have multiple treatment op-tionswith different mechanisms of action, as not all agentswork for all patients, and switching from one biologic toanother is a valid strategy when patients fail to respond orlose the response to any given agent (Gottlieb et al., 2012;Strober et al., 2011). Furthermore, psoriasis is a lifelong,chronic disease, and over time,many patientswill likely needto access numerous therapies for a host of reasons, such asloss of efficacy, comorbidities, life changes, development ofside effects, cost/insurance issues, and convenience. Devel-opment of drugs that target new pathways in psoriasis willincrease the number of options practitioners have to moreeffectively treat this complex disease in more patients.

Improved understanding of psoriasis as a chronic sys-temic disease and of the pathways responsible for the

manifestation of psoriatic plaques and inflammation hasprovided scientists with the opportunity to develop agentswith more specific targets. Clinicians, patients, and in-vestigators are hopeful that the results from early-stageclinical trials of newer agents will be confirmed in late-stage development. If this is the case, new treatments willjoin the most recently approved biologic, secukinumab, asadditions to an ever-expanding psoriasis armamentariumVprogress that should continue toopennew, life-changingdoorsfor patients with all types and degrees of psoriatic disease.h

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Aaronson, D. S., & Lebwohl, M. (2004). Review of therapy of psoriasis: Theprebiologic armamentarium. Dermatologic Clinics, 22(4), 379Y388, vii.

American Academy of Dermatology and AAD Association. (2013).Position statement on treatment of psoriatic patients. Retrieved fromhttp:/ /www.aad.org/Forms/Policies/Uploads/PS/PS%20on%20Treatment%20of%20Psoriatic%20Patients.pdf

Armstrong, A.W., Robertson, A. D., Wu, J., Schupp, C., & Lebwohl, M. G.(2013). Undertreatment, treatment trends, and treatment dissatisfactionamong patients with psoriasis and psoriatic arthritis in the United States:Findings from the National Psoriasis Foundation surveys, 2003Y2011.JAMA Dermatology, 149(10), 1180Y1185.

Baeten, D., Sieper, J., Emery, P., Braun, J., Van der Heijde, D., McInnes, I.,I Hueber, W. (2010). The anti-IL17A monoclonal antibodysecukinumab (AIN457) showed good safety and efficacy in the treatmentof active ankylosing spondylitis [abstract L7]. Arthritis and Rheumatol-ogy, 62(12), 3840.

Baker, C., Mack, A., Cooper, A., Fischer, G., Shumack, S., Sidhu, S., IFoley, P. (2013). Treatment goals for moderate to severe psoriasis: AnAustralian consensus. The Australasian Journal of Dermatology, 54(2),148Y154.

Barker, J., Hoffmann, M., Wozel, G., Ortonne, J. P., Zheng, H.,vanHoogstraten, H., & Reich, K. (2011). Efficacy and safety of infliximabvs. methotrexate in patients with moderate-to-severe plaque psoriasis: Re-sults of an open-label, active-controlled, randomized trial (RESTORE1).The British Journal of Dermatology, 165(5), 1109Y1117.

Benson, J. M., Peritt, D., Scallon, B. J., Heavner, G. A., Shealy, D. J.,Giles-Komar, J.M., &Mascelli, M. A. (2011). Discovery and mechanismof ustekinumab: A human monoclonal antibody targeting interleukin- 12and interleukin-23 for treatment of immune-mediated disorders. mAbs,3(6), 535Y545.

Bilac, C., Ermertcan, A. T., Bilac, D. B., Deveci, A., & Horasan, G. D.(2009). The relationship between symptoms and patient characteristicsamong psoriasis patients. Indian Journal of Dermatology, Venereologyand Leprology, 75(5), 551.

Cai, Y., Fleming, C., & Yan, J. (2013). Dermal +% T cellsVA new player inthe pathogenesis of psoriasis. International Immunopharmacology,16(3), 388Y391.

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