Cost-of-illness in patients with moderate to severe psoriasis: a cross-sectional survey in Hungarian dermatological centres

BACKGROUND

Despite the widespread availability of biological drugs in psoriasis, there is a shortage of disease burden studies.

OBJECTIVES

To assess the cost-of-illness and quality of life of patients with moderate to severe psoriasis in Hungary.

METHODS

Consecutive patients with Psoriasis Area and Severity Index (PASI) > 10 and Dermatology Life Quality Index (DLQI) > 10, or treated with traditional systemic (TST) or biological systemic treatment (BST) were included. Demographic data, clinical characteristics, psoriasis related medication, health care utilizations and employment status in the previous 12 months were recorded. Costing was performed from the societal perspective applying the human capital approach. Quality of life was assessed using DLQI and EQ-5D measures.

RESULTS

Two-hundred patients were involved (females 32%) with a mean age of 51 (SD 13) years, 103 (52%) patients were on BST. Mean PASI, DLQI and EQ-5D scores were 8 (SD 10), 6 (SD 7) and 0.69 (SD 0.3), respectively. The mean total cost was €9,254/patient/year (SD 8,502) with direct costs accounting for 86%. The main cost driver was BST (mean €7,339/patient/year). Total costs differed significantly across treatment subgroups, mean (SD): no systemic therapy €2,186 (4,165), TST €2,388 (4,106) and BST €15,790 (6,016) (p < 0,001). Patients with BST had better PASI and DLQI scores (p < 0.01) than the other two subgroups.

CONCLUSIONS

Patients with biological treatment have a significantly better quality of life and higher total costs than patients with or without traditional systemic treatment. Our study is the largest in Europe and the first in the CEE region that provides cost-of-illness data in psoriasis involving patients with BST.

Systemic Corticosteroids Are Frequently Prescribed for Psoriasis

Background:

The use of systemic corticosteroids is discouraged in major psoriasis treatment guidelines.

Purpose:

Our objective was to assess how often systemic corticosteroids are prescribed for psoriasis and trends in their use over time.

Methods:

We used National Ambulatory Medical Care Survey (NAMCS) data to determine the systemic medications prescribed for psoriasis from 1989 to 2010. We confirmed the findings by analysis of 2003–2007 MarketScan Medicaid data.

Results:

Systemic corticosteroids were prescribed at 650,000 (95% CI 380,000–920,000) of 21,000,000 psoriasis visits; 93% of these visits were to dermatologists. Of the top nine systemic medications listed at psoriasis visits, three of them were corticosteroids. Corticosteroids were the second most commonly prescribed systemic medication for psoriasis. No significant change in the use of systemic corticosteroids for psoriasis over time was observed ( p = .27). In the MarketScan data, prednisone was prescribed more commonly than either methotrexate or etanercept.

Limitations:

Corticosteroid doses and the length of treatment were not recorded in the NAMCS data.

Conclusions:

Systemic corticosteroids are among the most common systemic treatments used for psoriasis despite current guidelines. Data are acutely needed on the risks and benefits so that physicians and patients can make evidence-based decisions about their use.

Current practice of methotrexate use for psoriasis: results of a worldwide survey among dermatologists

BACKGROUND

Methotrexate is one the most commonly used systemic therapies for psoriasis. Despite its widespread use in psoriasis therapy, dermatologists' practice regarding the use of methotrexate has not been investigated on global scale.

OBJECTIVE

To evaluate the real life use of methotrexate for psoriasis treatment in the dermatological community worldwide.

METHODS

A questionnaire consisting of 41 questions was designed by the Psoriasis International Network (PIN). Questions focused on safety, dosing, administration, folic acid supplementation and combination therapy aspects of methotrexate use. The anonymous web-based survey was distributed to dermatologists by the national coordinators of PIN.

RESULTS

Between 2 April and 7 August 2012, 481 dermatologists from 63 countries completed the questionnaire. Most respondents were from European and South American countries, whereas the response rate from Central America and the Near East was lowest. The majority of responders were experienced dermatologists (86% had more than 5 years of experience in psoriasis treatment). Starting and maintenance doses of 10 mg of methotrexate or lower were reported by 67% and 42% of respondents respectively. Thirty-eight per cent of respondents stop treatment at a cumulative dose of 2 g, whereas 36% did not consider cumulative dose important in this respect. The primary mode of administration was oral, and the majority of respondents administer folic acid supplementation. Almost all respondents monitored full blood count, liver and renal function tests, whereas procollagen 3 amino terminal peptide measurement and transient elastography is used by only a minority of dermatologists. There were significant differences concerning the doses, routes of administration and safety monitoring among the clinical practices in different geographical locations.

CONCLUSION

Current clinical practice of methotrexate use in psoriasis is not uniform, depends on geographical location, and is not in full agreement with clinical guidelines.

Adherence to guidelines in the use of biological agents to treat psoriasis in Brazil

OBJECTIVE

In São Paolo, Brazil, patients can appeal to the courts, registering law suits against the government claiming the need for biological agents for treatment of psoriasis. If the lawsuits are successful, which is usually the case, the government then pays for the biologic agent. The extent to which the management of such patients, after gaining access to government payment for their biologic agents, adheres to authoritative guidelines, is uncertain.

METHODS

We identified patients through records of the State Health Secretariat of São Paulo from 2004 to 2011. We consulted guidelines from five countries and chose as standards only those recommendations that the guidelines uniformly endorsed. Pharmacy records provided data regarding biological use. Guidelines not only recommended biological agents only in patients with severe psoriasis who had failed to respond to topical and systemic therapies (eg, ciclosporin and methotrexate) but also yearly monitoring of blood counts and liver function.

RESULTS

Of 218 patients identified in the database, 3 did not meet eligibility criteria and 12 declined participation. Of the 203 patients interviewed, 91 were still using biological medicine; we established adherence to laboratory monitoring in these patients. In the total sample, management failed to meet standards of prior use of topical and systemic medication in 169 (83.2%) patients. Of the 91 patients using biological medicine at the time of the survey, 23 (25.2%) did not undergo appropriate laboratory tests.

CONCLUSIONS

Important discrepancies exist between clinical practice and the recommendations of guidelines in the management of plaintiffs using biological drugs to treat psoriasis.

Economic impact of new active substance status on EU payers' budgets: example of dimethyl fumarate (Tecfidera(®)) for multiple sclerosis

BACKGROUND

Recently, collaboration between regulators and payers was set up and was mainly focused on evidence generation along product clinical development. However, neither the regulatory path nor the new active substance status (NASs) was considered. Granting NASs will provide the product with 8 years of data protection and 2 years of market exclusivity during which no generic could enter the market.

OBJECTIVE

To review the economic impact (for payers) of NASs granted by the European Medicines Agency (EMA) for dimethyl fumarate (DMF), developed by Biogen and approved for multiple sclerosis (MS) as Tecfidera(®) on 3 February 2014.

METHOD

We reviewed the available DMF-containing products and identified their indication and price through relevant databases and official Web sites. The economic impact of Tecfidera(®) on payers' budgets was calculated assuming NASs was or was not granted. The forecast was identified in Datamonitor.

RESULTS

Results identified four products already containing DMF as the main or unique active substance. This would have potentially prevented Tecfidera(®) from being granted NASs. The EMA Committee for Medicinal Products for Human Use (CHMP) denied Tecfidera(®) NASs and, following a company appeal, reversed its position opening as polemic. The impact of that decision has been evaluated at €7 to €10 billion over a 10-year period.

CONCLUSION

NASs is a critical decision because it does have a major budget impact for payers, and it prevents generic competition. Current European Union (EU) regulations on that topic are unclear and open up too many interpretations thus distorting fair trade and affecting payers' bills. Greater clarity and more stringent rules are required to prevent mistrust of this EMA decision.

Tecfidera®: an approach for repurposing

As a case study of patent coverage for a repurposed drug, Biogen Idec’s approach for Tecfidera®, an oral formulation of dimethyl fumarate, was analyzed. While mixtures of fumarates have been used for over 50 years to treat psoriasis, Tecifidera is approved for the treatment of relapsing-remitting multiple sclerosis. Biogen pursued claims to pharmaceutical formulations and useful doses for treating multiple sclerosis, an approach that is relevant to pharmaceutical lifecycle management in general. A survey of recent US, EP, and PCT patent applications indicate other companies are developing competing fumarate formulations. While it is possible to pursue secondary patents for compounds without composition of matter coverage, regulatory data exclusivity provides additional protection to delay competitors.

Effectiveness and safety of fumaric acid esters in children with psoriasis: a retrospective analysis of 14 patients from The Netherlands

BACKGROUND

Fumaric acid esters (FAE) are used as an effective and safe oral treatment for plaque psoriasis in adult patients, but little is known about their efficacy and safety in children with psoriasis.

OBJECTIVES

To assess the effectiveness and safety of FAE in the treatment of paediatric psoriasis.

METHODS

This is a retrospective analysis of 14 paediatric patients with psoriasis (age <18 years) treated with FAE between 2004 and 2012 at several Dutch university and regional clinics. Patients were identified through databases or registries.

RESULTS

The median age at the start of FAE treatment was 15 years (range 8-17 years). The median duration of FAE treatment was 10 months (range 1-80 months), and the median maintenance dosage per day was 360 mg dimethylfumarate (range 240-600 mg). Five patients (36%) achieved a complete clearance of their psoriasis, one patient (7%) had a good improvement, three patients (21%) had a partial response and five patients (36%) were nonresponders. FAE treatment was well tolerated, but two patients (14%) discontinued FAE, one with severe diarrhoea and one with flushes. Five patients (36%) had transient, slightly abnormal laboratory values of liver-function tests or leucocytes that did not necessitate FAE dosage reduction or treatment discontinuation. No serious adverse events occurred.

CONCLUSIONS

In this retrospective case series FAE seemed to be an effective and safe treatment for children with psoriasis. FAE may be an attractive therapeutic alternative to the currently used systemic immunosuppressive agents for paediatric patients with psoriasis. Further studies are needed to evaluate the suitability of FAE in paediatric psoriasis.

Therapeutic strategies in psoriasis patients with psoriatic arthritis: focus on new agents

Psoriatic arthritis affects approximately 6-42 % of patients with psoriasis. It is useful for physicians or dermatologists managing psoriasis patients to be aware of how to concurrently manage the joint manifestations, as it is preferable and convenient to use a single agent in such patients. However, only certain therapies are effective for both. Systemic agents, which can be used for both skin and joint manifestations, include methotrexate and ciclosporin. For the group of biologic agents, the tumor necrosis factor inhibitors such as adalimumab, etanercept, infliximab, golimumab and certolizumab are effective. Ustekinumab is a more recently developed agent belonging to the group of anti-IL-12p40 antibodies and has been shown to be efficacious. Newer drugs in the treatment armamentarium that have shown efficacy for both psoriasis and psoriatic arthritis consist of the anti-IL-17 agent, secukinumab, and a phosphodiesterase-4 inhibitor, apremilast. The other anti-IL-17 agents, ixekizumab and brodalumab, as well as the oral Jak inhibitor, tofacitinib, have very limited but promising data. This review paper provides a good overview of the agents that can be used for the concurrent management of skin and joint psoriasis.

Predictors of biologic treatment of psoriasis: a non-interventional study

Background

Biologic therapies represent a significant advance in the treatment of psoriasis. However, no studies have examined the patient characteristics predictive of biologic treatment of psoriasis. The purpose of this study was to ascertain the frequency and predictors of treatment of psoriasis with biologics in three European countries, ie, France, Spain, and the UK.

Methods

This was a cross-sectional analysis of physician-recorded demographic and clinical data on patients receiving either conventional or biologic treatments for psoriasis. Data were drawn from the Adelphi 2007 Psoriasis Disease Specific Program (DSP®), a multinational, real-world survey of patients with psoriasis consulting practicing dermatologists. The numbers of patients treated with biologic and nonbiologic agents were recorded. Data were subjected to bivariate analysis according to treatment regimen (biologic versus nonbiologic). Predictors of treatment with biologics were identified by logistic regression analysis.

Results

A total of 2,509 psoriasis patients were included in this study (1,374 from France, 561 from Spain, and 574 from the UK). Biologic use was most prevalent in Spain (19.4% of patients), followed by the UK (9.1%), and France (8.4%). In the logistic regression analysis, psoriatic arthritis was a statistically significant predictor of increased biologic use in France (odds ratio [OR] 5.38, 95% confidence interval [CI] 3.32–8.77), Spain (OR 2.71, 95% CI 1.16–6.33), and the UK (OR 8.70, 95% CI 3.65–20.83). Physician-assessed moderate-to-severe disease was also a statistically significant predictor of increased biologic use in France (OR 5.08, 95% CI 2.01–12.82), Spain (OR 11.11, 95% CI 4.33–28.57), and the UK (OR 8.55, 95% CI 1.11–66.67).

Conclusion

In this study, an average of about one tenth of psoriasis patients enrolled in Spain, France, and the UK were treated with biologics in 2007. Physician-assessed moderate-to-severe disease and presence of psoriatic arthritis were significantly associated with biologic use in all three countries.

Outcome of patients with serology suggestive of past hepatitis B virus infection during antitumor necrosis factor therapy for psoriasis

BACKGROUND

Recently, the reactivation during treatment with tumor necrosis factor (TNF) blockers has exceptionally been described in patients with hepatitis B virus (HBV) antigen-negative (HBsAg). The objective was to evaluate the influence of anti-TNF agents in patients with psoriasis and serology suggesting past hepatitis B state.

METHODS

The inclusion criteria were chronic plaque psoriasis treated with anti-TNF therapy, HBsAg-negative, and HBcAb-positive. We gathered the demographic data and type and duration of anti-TNF agent. Serum aminotransferase levels and HBV serologic status were requested at baseline and during follow-up.

RESULTS

We have included 13 patients (four women, nine men) (mean age of 62.1 years). The agent was etanercept in seven cases, infliximab in four patients, and adalimumab in the other two. The mean duration of TNF therapy was 28.6 months. None of them became HBsAg-positive. Neither signs nor symptoms of acute hepatitis were reported.

CONCLUSION

The management of HBsAg-negative patients is unresolved. Only nine cases of HBV reactivation during treatment with TNF blockers have been reported. Despite the low risk of reactivation in these patients, we recommend the monitoring of serum aminotransferase levels, HBsAb titers, HBsAg and, if possible, viral load.

Treatment of psoriasis: focus on clinic-based management with infliximab

Psoriasis is a disabling chronic inflammatory condition of the skin and joints that typically requires long-term treatment. Recommended treatments for psoriasis include a wide range of topical and systemic options, from topical agents and targeted phototherapy for mild psoriasis to traditional systemic agents such as methotrexate, cyclosporine and acitretin for more serious disease. The introduction of targeted biological agents such as T-cell-modulating agents, tumor necrosis factor α (TNFα) antagonists and interleukin (IL)-12 and IL-23 inhibitors has provided new choices for the management of psoriasis and psoriatic arthritis that may offer better long-term efficacy and tolerability than traditional approaches. Most biological agents are administered by subcutaneous injection. Infliximab, a TNFα antagonist, is the only biological agent approved for psoriasis that is administered by intravenous infusion, in the setting of hospital-based or specialized infusion center-based clinics. Infliximab allows weight-based dosing and may offer more rapid disease control than other biological agents, with significant improvements seen as early as 1 week after treatment initiation. This article gives an overview of psoriasis management, focusing on clinic-based infusion therapy with infliximab.

Safety and tolerability of tumor necrosis factor-α inhibitors in psoriasis: a narrative review

Tumor necrosis factor (TNF)-α inhibitors are an alternative to oral systemic therapies for psoriasis. Data regarding the safety of TNF-α inhibitors from randomized clinical trials may not fully reflect the effects on the clinic patient population receiving the therapy, but other sources of information are available. We performed a literature review to assess the safety and tolerability of the treatment of moderate-to-severe plaque psoriasis with TNF-α inhibitors. A literature search was conducted using PubMed for articles dating from January 2000 to October 2013. Randomized controlled, cohort, open-label, and observational studies were included, as well as case reports and letters to the editor. Articles found on PubMed describing the safety of anti-TNF-α therapy in psoriasis patients were included, while studies highlighting interleukin (IL)-12 and IL-23 inhibitors were excluded, as were non-English articles. In total, 58 articles were included in the review. TNF-α inhibitors exhibit both efficacy and tolerability in patients with moderate-to-severe plaque psoriasis. Adverse effects associated with these medications are not common and can be minimized with routine clinical monitoring and patient education. While the risk of severe adverse events is low, the lack of very large, long-term, randomized safety trials limits the ability to fully define the safety of these agents. TNF-α inhibitors have a good efficacy/safety ratio for use in patients with moderate-to-severe psoriasis. Serious adverse effects are not common, and common injection-site reactions are usually manageable. The benefits of TNF-α inhibitors outweigh the risks for moderate-to-severe psoriasis; however, there are potential adverse effects and the patient populations at highest risk include the elderly and those with a history of malignancy.

Immune-mediated inflammatory reactions and tumors as skin side effects of inflammatory bowel disease therapy

All drugs currently used for treating patients with inflammatory bowel disease (IBD - including Crohn's disease and ulcerative colitis) have the potential to induce skin lesions ranging from mild eruptions to more serious and widespread clinical presentations. The number of cutaneous adverse reactions due to IBD therapies is progressively increasing and the most frequently involved drugs are thiopurines and biologics like tumor necrosis factor (TNF)-α antagonists. The main drug-induced cutaneous manifestations are non-melanoma skin cancer (NMSC), notably basal cell and squamous cell carcinomas, and viral skin infections for thiopurines and psoriasiform, eczematoid and lichenoid eruptions as well as skin infections and cutaneous lupus erythematosus for biologics. Cutaneous manifestations should be promptly recognized and correctly diagnosed in order to quickly establish an adequate therapy. The main treatment for NMSC is surgical excision whereas the management of immune-mediated inflammatory skin reactions varies from topical therapy for mild presentations to the shift to another drug alone or in combination with corticosteroids for extensive eruptions.

Social problem-solving, perceived stress, negative life events, depression and life satisfaction in psoriasis

BACKGROUND

Psoriasis is a chronic dermatosis which may cause significant impairment of the patient's quality of life.

OBJECTIVE

The purpose of this study was to investigate the social problem-solving skills, perceived stress, negative life events, depression and life satisfaction in psoriasis patients.

METHODS

Data were gathered by means of questionnaires and clinical evaluations from 51 psoriatic patients and 51 matched healthy controls.

RESULTS

Average disease duration was 16.47 years and average Psoriasis Area and Severity Index score was 3.67. Compared with the controls, the patients displayed lower social problem-solving skills. They displayed higher negative problem orientation and impulsive-careless problem-solving style scores than the controls. Patients tended also to show more avoidant problem-solving style and lower life satisfaction than controls. There was no difference between psoriatic patients and controls in terms of depression, perceived stress and negative life events. Higher social problem-solving skills were associated with lower depression, perceived stress and fewer numbers of negative life events but higher level of life satisfaction.

LIMITATIONS

The patient group largely included mild and moderate psoriatic cases.

CONCLUSION

The findings of the study suggest that problem-solving training or therapy may be a suitable option for alleviating levels of psychological distress in patients suffering from psoriasis.

Patient considerations and targeted therapies in the management of psoriasis in Chinese patients: role of ustekinumab

Psoriasis is an immune-mediated disease affecting approximately 0.1% to 0.5% of the population in the People's Republic of China. Multiple therapeutic options are available for the treatment of moderate to severe psoriasis although they all have their respective disadvantages. The application of biological agents has brought significant efficacy in psoriasis treatment. Ustekinumab, a human monoclonal antibody targeting the interleukin-12/23 pathway, shows its superiority in efficacy, long duration of drug action, and good tolerance in patients. Phase III clinical trials of ustekinumab have been completed in Mainland China, and the drug is available in Taiwan and Hong Kong. Meanwhile, its long-term safety and efficacy merit further investigation.

Personal treatment experience for severe generalized pustular psoriasis of pregnancy: two case reports

Generalized pustular psoriasis of pregnancy (GPPP) is a rare and severe variant of pustular psoriasis. It has been called the most dangerous and life-threatening dermatosis in pregnant woman. To explore the treatment of GPPP, we conducted a retrospective study of two cases of GPPP in our clinic and other related reported cases and manuscripts. In 1992, a GPPP patient came to our clinic. We prescribed her antibiotics and dexamethasone. The pregnancy was artificially terminated. After delivery, she took a retinoid and a topical steroid and recovered progressively. In 2012, we treated another GPPP patient. Methylprednisolone and cyclosporine were administered. Maternal and fetal statuses were monitored closely. The treatment was effective and a healthy baby was delivered. We compared our two GPPP cases and found that cyclosporine and a sufficient dosage of steroid were an effective treatment. Antibiotics could be tried in mild cases or the initial stages before excluding sepsis. Based on other reported GPPP cases, TNF-α antagonists are used as rescue therapy in GPPP refractory to steroid and cyclosporine therapy, but careful consideration of the advantages and disadvantages is warranted before using them. Supportive measures are necessary to maintain pregnancy and prevent complications in cases of GPPP.

A comparison of the effects of topical treatment of calcipotriol, camptothecin, clobetasol and tazarotene on an imiquimod-induced psoriasis-like mouse model

The interleukin-23/interleukin 17A (IL-23/IL-17A) cytokine axis plays a critical role in the pathogenesis of psoriasis. In this study, we report the effects of topical calcipotriol, camptothecin, clobetasol and tazarotene on the treatment of imiquimod (IMQ)-induced psoriasis-like inflammation, the development of which is dependent on the IL-23/IL-17A axis. IMQ-induced epidermal hyperplasia and inflammation in the BALB/c mouse ear were significantly inhibited following clobetasol treatment but not calcipotriol, camptothecin or tazarotene treatments. Real-time polymerase chain reaction showed that the mRNA levels of IL-17A, IL-17F, IL-22, IL-1β, IL-6 and TNF-α in ear skin were significantly decreased by clobetasol. In addition, we observed that calcipotriol, camptothecin and tazarotene failed to show any inhibitory effects on the IL-23/IL-17A/IL-22 axis. We also found that clobetasol treatment inhibited the proliferation of γδ T cells and C-C chemokine receptor type 6 (CCR6) expression induced by IMQ. Calcipotriol, camptothecin and tazarotene not only failed to inhibit this proliferation but also enhanced retinoic acid-related orphan receptor γ (RORγ) expression in IMQ-induced psoriasis-like inflammation. In conclusion, we suggest that clobetasol induces the relief of IMQ-induced psoriasis-like inflammation in a mouse model but that calcipotriol, camptothecin and tazarotene cannot. Therefore, we suggest that more in-depth studies on pharmacological effects of tazarotene, camptothecin and calcipotriol should be carried out.

Psoriasis, cardiovascular events, cancer risk and alcohol use: evidence-based recommendations based on systematic review and expert opinion

The relationship between psoriasis, chronic inflammation, cardiovascular risk and risk of cancer has long been debated. In addition, it has been suggested that alcohol consumption may be a risk factor for psoriasis onset and severity. The aim of this study was to develop evidence-based recommendations on the risk of comorbidities and its management for daily clinical use, focusing on cardiovascular risk, risk of cancer and alcohol use in psoriasis. A scientific committee identified and selected through the Delphi method clinically relevant questions about cardiovascular risk, risk of cancer and alcohol use in psoriasis. To address these questions, a systematic literature search was performed in Medline, Embase and the Cochrane Library databases. Systematic literature reviews including meta-analysis whenever possible were performed. Subsequently, an Expert board meeting involving 39 dermatologists took place to analyse the evidence and to elaborate recommendations on the selected questions. Recommendations were graded according to the Oxford level of evidence grading system. The degree of agreement of these recommendations was assessed on a 10-point scale, as well as their potential impact on daily clinical practice. A total of 3242 articles were identified through the systematic literature searches, among which 110 were included in the systematic reviews. Overall, 12 recommendations were elaborated regarding comorbidities management in psoriasis patients. A moderate increased risk of cardiovascular diseases (CVD), mainly myocardial infarction (MI) [meta-analysis of cohort studies: OR = 1.25 (95% CI 1.03-1.52) and of cross-sectional studies: OR = 1.57 (95% CI 1.08-2.27)], and coronary artery disease (CAD) [meta-analysis of cross-sectional: OR = 1.19 (95% CI 1.14-1.24), of cohort studies: OR = 1.20 (95% CI 1.13-1.27) and of case-control studies: OR = 1.84 (95% CI 1.09-3.09)] was acknowledged. This increased cardiovascular risk requires appropriate prevention measures. There was a lack of substantial evidence that conventional systemic treatment has any effect on cardiovascular risk although methotrexate might be cardioprotective. An increased risk of solid cancer potentially associated with smoking and alcohol use was identified. The role of systemic treatment on cancer risk could not be assessed thoroughly due to limited long-term follow-up data. A higher risk of non-melanoma skin cancers especially squamous cell carcinoma was shown, mainly due to previous exposure to oral 8-methoxypsoralen-ultraviolet-A (PUVA), ciclosporin and possibly methotrexate. No firm conclusion could be drawn regarding alcohol and psoriasis due to high variability in alcohol usage assessment in studies. Clinical experience suggests higher alcohol consumption among psoriasis patients compared to the general population. The mean expert participants' level of agreement on these recommendations varied from 6.8 to 9.4. These 12 recommendations are evidence based and supported by a panel of expert dermatologists. The next step is now to disseminate these recommendations to dermatologists who did not participate in the Expert board meeting and to assess their opinion about the recommendations.

Burden of disease: psoriasis and psoriatic arthritis

Psoriatic arthritis (PsA) increases the disease burden associated with psoriasis by further diminishing quality of life, increasing health care costs and cardiovascular risk, and potentially causing progressive joint damage. The presence of PsA influences psoriasis treatment by increasing overall disease complexity and, within the framework of current guidelines and recommendations, requiring the use of conventional disease-modifying anti-rheumatic drugs or tumor necrosis factor-α inhibitors in order to prevent progressive joint damage. Despite its important impact, PsA is still under-diagnosed in dermatology practice. Dermatologists are well positioned to recognize and treat PsA, given that it characteristically presents, on average, 10 years subsequent to the appearance of skin symptoms. Regular screening of psoriasis patients for early evident joint symptoms should be incorporated into daily dermatologic practice. Although drugs effective in PsA are available, not all patients may respond to treatment, and others may lose their initial response over time. New investigational therapies, such as inhibitors of interleukin-17A, interleukin-12/23, Janus kinase 3, or phosphodiesterase-4, may address unmet needs in psoriatic disease, with further research needed to determine the role of these agents in reducing joint damage and other comorbidities.

Combined Clinical, Capillaroscopic and Ultrasound Evaluation during Treatment of Plaque Psoriasis with Oral Cyclosporine

Imaging techniques have only recently been utilized in combination with clinical observation to objectively quantify psoriasis severity and evaluate therapeutic response. This study evaluated the sensitivity of videodermatoscopy (VD) and ultrasound (US) imaging to assess the therapeutic effect of cyclosporine (Cs) in patients with moderate-to-severe psoriasis. Twenty patients with moderate-to-severe psoriasis were divided into two groups (A and B) based on PASI score. Group A (PASI >16) was treated with 5 mg/Kg/day Cs for 4 weeks and another 4 weeks with 3 mg/Kg/day Cs. Group B (PASI 1016) received 3 mg/Kg/day Cs for 8 weeks. A “target” plaque was selected for each subject and evaluated using a Target Lesion Score (TLS) for erythema, scaling and degree of infiltration, in addition to VD and US at baseline, 2, 4 and 8 weeks. At the end of the study, improvement rate was quicker in group A vs group B after 8 weeks of Cs therapy. All three parameters (TLS, VD and US) strongly correlated with one another. Skin thickness was the first parameter that improved, followed by TLS. In contrast, improvement in VD was delayed. Normalization rate of vascular pattern (assessed by VD) was low in both groups but higher in group A vs group B (46% vs 22%), despite virtually complete normalization by clinical and US assessment. In conclusion, while both TLS and US can be utilized in the evaluation of therapeutic efficacy in patients with plaque psoriasis, VD can provide information on vascular response to treatment, which may likely affect the duration of therapy and the relapse rates.

Safety results from a pooled analysis of randomized, controlled phase II and III clinical trials and interim data from an open-label extension trial of the interleukin-12/23 monoclonal antibody, briakinumab, in moderate to severe psoriasis

BACKGROUND

Anti-interleukin-12/23 treatment (anti-IL-12/23) has recently demonstrated significant efficacy for moderate to severe psoriasis, yet potential safety signals warrant further investigation.

OBJECTIVES

Expand safety findings for the anti-IL-12/23, briakinumab, beyond individual phase II and III clinical trials.

METHODS

Safety data pooled from five phase II and III clinical trials (parent studies) and an open-label extension study (OLE), through 22 October 2010; patients with ≥ 1 dose of briakinumab in a parent study or the OLE are included. All parent study briakinumab treatment groups were combined with the OLE population, which received 100-mg briakinumab every 4 weeks. Adverse events (AEs) were collected from the first dose of briakinumab, whether in a parent study or the OLE, through 45 days post-last dose.

RESULTS

Two thousand five hundred and twenty patients (4704 patient-years drug exposure) received ≥ 1 dose of briakinumab during the interim period: 5.6% withdrew due to AEs. Serious infections occurred in 1.3% and malignancies in 2.6% (including 1.0% basal cell carcinoma, 0.8% squamous cell carcinoma). Twenty-seven major adverse cardiovascular events (MACE) occurred, seven in one parent study and 20 in the OLE (incidence = 0.57 events/100 PY). Four cardiovascular risk factors were retrospectively found to be significant predictors for MACE during briakinumab exposure: history of cardiovascular disease, diabetes, body mass index (≥ 30) and baseline blood pressure (systolic ≥ 140 or diastolic ≥ 90).

CONCLUSIONS

Pooled briakinumab safety results from five parent studies and an OLE suggest increased rates of infections, malignancies and MACE, and that patients receiving anti-IL-12/23 treatment for moderate to severe psoriasis should be monitored for these potential safety signals.

Differences between post-authorization adverse drug reactions of biopharmaceuticals and small molecules

BACKGROUND

The nature of adverse drug reactions observed post-authorization for biopharmaceuticals differs from that observed for chemically synthesized, small molecules (SMs). However, it remains unclear how much of the observed differences can be attributed to differences in authorized indications of the two product groups.

OBJECTIVE

To investigate if the nature of adverse drug reactions identified post-authorization for biopharmaceuticals differs from those of SMs within the same anatomical therapeutic chemical (ATC) group.

METHODS

We analyzed safety issues included in post-authorization, changes to the Summary of Product Characteristics of centrally approved products in the European Union classified in the ATC main group of 'antineoplastic and immunomodulating agents'. Generics and biosimilars were excluded. All issues identified during 2004-2011 were analyzed for differences in nature and timing between biopharmaceutical and SM products, at different ATC levels.

RESULTS

A total of 747 adverse drug reactions were identified; 361 for biopharmaceuticals and 386 for SMs. Within the sub group of immunosuppressants, neoplasms (20 % vs 2 %, p < 0.01) and infections and infestations (22 % vs 9 %, p < 0.01) occurred significantly more frequent for biopharmaceuticals. Adverse drug reactions of SMs were more often renal and urinary disorders (7 % vs 0 %, p < 0.01), blood and lymphatic system disorders (10 % vs 3 %, p = 0.04), and vascular disorders (7 % vs 1 %, p = 0.02). In the subgroup of antineoplastics, immune system disorders occurred more frequently for biopharmaceuticals, (6 % vs 1 %, p = 0.04). With the exception of immune system disorders and renal disorders, the overall differences between biopharmaceuticals and SMs were mostly caused by products authorized as immunosuppressants. For the subset of products authorized after 2004, the median time to the first safety issue was 18 months (95 % CI 12.4-21.5) for biopharmaceuticals and 17 months (95 % CI 12.5-21.5) for SMs and did not differ significantly within subgroups.

CONCLUSION

Even within a group of medicinal products approved in the same indication, differences were observed in the nature of adverse drug reactions between biopharmaceuticals and SMs. The considerable differences in the nature of adverse drug reactions between biopharmaceuticals and SMs were not associated with differences in the timing of regulatory actions.

Safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and chronic viral hepatitis B or C: a retrospective, multicentre study in a clinical setting

BACKGROUND

Both the safety and efficacy of biologic therapy may be affected in the presence of highly prevalent chronic viral hepatitis.

OBJECTIVE

To evaluate the safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and concomitant chronic viral hepatitis.

METHODS

This was a retrospective, multicentre study. Twenty-five patients with psoriasis and concurrent hepatitis C virus (HCV) (20 patients) or hepatitis B virus (HBV) (five patients) infection who had received at least one biologic agent (etanercept, 21 treatments; adalimumab, four; ustekinumab, four; infliximab, two) were included. Clinical, imaging and laboratory data were recorded.

RESULTS

In the case of HCV infection, the majority of the patients did not exhibit increases in their viral load or serum liver tests. Aspartate aminotransferase, alanine aminotransferase and gamma glutamyl transpeptidase were doubled from the baseline measurement in only one patient treated with etanercept. Two other cases exhibited viral load increases during the follow-up period. In total, 18 of the 26 treatments achieved a 75% improvement in their Psoriasis Area and Severity Index (PASI 75) score during the follow-up period. Two patients treated with etanercept were diagnosed with hepatocellular carcinoma. In the case of HBV infection, all of the patients were being treated with antiviral therapy, and none presented significant variations in viral load or serum liver enzymes. All patients achieved a PASI 75 during follow-up.

CONCLUSIONS

Biologic therapy was effective and safe for the majority of our patients with HCV and HBV infection, although there may be a risk of reactivation or aggravation. We describe the first cases to receive ustekinumab. The use of biologics should be limited to those cases in which the risk-benefit ratio is justified.

Add-on effect of chinese herbal medicine bath to phototherapy for psoriasis vulgaris: a systematic review

Psoriasis vulgaris is the most common form of psoriasis. Phototherapy has been proven effective for psoriasis, but side effects have become a concern. Chinese herbal medicine (CHM) bath combined with phototherapy has been used in clinical settings, but the additional benefit requires evaluation. This review aims to evaluate the additional benefit and safety of adding CHM bath to phototherapy for psoriasis vulgaris. Cochrane library, PubMed, Embase, CNKI, and CQVIP were searched from their inceptions to 6 August 2012. Randomized controlled trials (RCTs) comparing CHM bath plus phototherapy to phototherapy alone for psoriasis vulgaris were included. Data was analyzed using Review Manager 5.1.0. Thirteen RCTs were included in the review, and eight were included in the meta-analysis. Meta-analysis showed higher efficacy of CHM bath plus phototherapy when compared with phototherapy alone in terms of PASI 60 (RR 1.25; 95% CI: 1.18-1.32). Mild adverse events were reported in ten studies, but these could be alleviated by reducing UV dosage or applying emollient. In conclusion, CHM bath appears to be a beneficial and safe adjunctive therapy to phototherapy for psoriasis vulgaris. However, these results should be interpreted with caution due to the low methodological quality of the included studies.

Cyclosporine regimens in plaque psoriasis: an overview with special emphasis on dose, duration, and old and new treatment approaches

Cyclosporine A (CsA) is one of the most effective systemic drugs available for the treatment of psoriasis, as evidenced by the results of several randomized studies and by a prolonged experience in dermatological setting. In clinical practice, CsA is usually used for the induction of psoriasis remission at a daily dose included in the range of 2.5–5 mg/kg and with intermittent short-term regimens, lasting on average 3–6 months. The magnitude and rapidity of response are dose dependent, as well as the risk of development of adverse events. Therefore, the dose should be tailored to patient's needs and general characteristics and adjusted during the treatment course according to both the efficacy and tolerability. Some studies support the feasibility of pulse administration of CsA for a few days per week for both the induction and the maintenance of response in psoriasis patients. This paper will review the data on CsA regimens for plaque-type psoriasis and will focus the attention on dose, treatment duration, novel schedules, and role in combination therapies, including the association with biologicals.

Psoriasis and psycho-dermatology

Introduction

Psoriasis is a common, long-term skin condition associated with high levels of psychological distress and considerable life impact. The impact of psoriasis, beyond the skin, is often not recognised and under-treated.

Methods

This paper explores the relationship between psychological distress and psoriasis including reference to the ‘brain–skin access’. The life impact of psoriasis is discussed and pharmacological interventions which affect distress associated with psoriasis and psychological interventions are reviewed. Evidence from peer-reviewed journals and controlled trials inform the text.

Results

Psoriasis has a profound impact on mental health and well-being which is under-recognised by clinicians. The sympathetic adrenal medullary axis and hypothalamic pituitary adrenal axis are likely to be involved in the onset of psoriasis and there may also be an effect from inflammation in the skin on the central release of corticotrophin-releasing hormone. Psoriasis can be stigmatising and may affect all aspects of life including relationships, employment, social life and leisure activities. There is some evidence for psychological interventions being effective in the management of distress associated with psoriasis and psoriasis itself. Studies, however, have used disparate outcomes and methods and largely involve low numbers of patients. There is very limited access to psychological support for the patients with psoriasis despite evidence of high levels of psychological distress and considerable life impact.

Conclusions

Psoriasis is a long-term skin condition associated with high levels of distress and considerable life impact, both of which are under-recognised. Routine screening for distress with access to effective treatment is required. There is a need for high-quality studies to assess the effect of psychological intervention in patients with psoriasis both to inform guidance and facilitate the provision of effective psychological support services.

Long-Term Cost-Effectiveness Analysis of Etanercept and Adalimumab for Plaque Psoriasis not Associated with Arthritis

Introduction

Pharmacoeconomic studies examining the cost-effectiveness of biological agents to treat moderate-to-severe psoriasis in real-life clinical practice are scarce. The aim of this study was to assess the efficiency, in terms of incremental cost-effectiveness, of etanercept and adalimumab in a real clinical setting.

Methods

Direct and indirect costs were assessed from a Spanish societal perspective in a historical hospital cohort of patients with moderate-to-severe psoriasis attending a tertiary referral hospital over a 1-year period. The data examined included drug-related variables, use of health-care resources, transportation and work productivity losses. Effectiveness was measured as the proportion of patients achieving a reduction of at least 75% with respect to the baseline value for the Psoriasis Area Severity Index (PASI 75) during the first 52 weeks of treatment.

Results

No statistically significant differences in effectiveness between etanercept (n = 135) and adalimumab (n = 48) were found (PASI 75 80% vs. 85.7%; RR = 1.07 [0.90, 1.27]; RRA = 5.7 [−8.9, 20.2]; p = 0.943). There were no significant differences in total cost per patient with etanercept as compared to adalimumab (14,843.73 ± 6,178.98 € vs. 15,405.91 ± 9,106.50 €; p = 0.768).

Conclusion

Under conditions of daily clinical practice in our hospital, total health-care costs associated with the treatment of moderate-to-severe psoriasis with etanercept appear to be equivalent to those with adalimumab in the first year of treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-013-0030-1) contains supplementary material, which is available to authorized users.

Barriers to the prescription of systemic therapies for moderate-to-severe psoriasis--a multinational cross-sectional study

Despite the availability of a plethora of approved systemic treatments, high proportions of patients with moderate-to-severe psoriasis do not receive systemic treatment. This study aims at identifying barriers that hinder dermatologists from prescribing systemic treatments for psoriasis. A cross-sectional online survey in six countries (Canada, Germany, Spain, France, Italy, UK) was performed among 300 dermatologists, assessing the relevance of 15 potential barriers towards prescribing acitretin, cyclosporine, methotrexate, adalimumab, etanercept, infliximab and ustekinumab. Multivariate regression analyses were used to explore provider characteristics related to these barriers. Treatment barriers are perceived differently in the countries investigated, with Spanish, Italian and Canadian dermatologists being particularly concerned about the safety of methotrexate and Canadian dermatologists about the safety of cyclosporine. In general, safety concerns were the most important barrier to the use of cyclosporine, (18 % of participants' moderate/9 % strong or very strong barrier). Costs were being perceived as a strong or very strong barrier to the use of the different biologics by 19-24 % of the participants. Overall, country and work place were the most important determinants of treatment barriers. Sex, age, training, position and experience were minor determinants of treatment barriers. Medical reasons such as safety concerns or an inappropriate risk-benefit profile are particularly relevant barriers to the prescription of conventional treatments; whereas for biological treatments, economic reasons such as costs are more prevalent. Country specific analysis showed national differences in the perception of safety. The treatment barriers identified in this exploratory study should be confirmed in further health services research.

IL-17 targeted therapies for psoriasis

INTRODUCTION

Psoriasis is a chronic, disabling, inflammatory skin disease whose pathogenesis still remains to be fully elucidated. Genetic and environmental factors induce an immune response mediated by several cytokines and chemokines, including IL-17A.

AREAS COVERED

Emerging evidence now suggests that IL-17A is central in the pathogenesis of psoriasis. Three agents neutralizing IL-17 (i.e., secukinumab and ixekizumab) or antagonizing its receptor (i.e., brodalumab) are in development and are being studied in Phase III clinical trials to evaluate their overall efficacy and safety. However, Phase II results of IL-17 blockade with each of these agents has shown a marked improvement of disease severity, thus confirming the pathogenic relevance of IL-17 in mediating crucial inflammatory circuits in psoriasis.

EXPERT OPINION

Anti-IL-17 agents are likely to become important future therapeutics in this disease and the may potentially impact on cardiovascular diseases, arthritis and other comorbidities associated with psoriasis.

Psoriasis, anti-tumor necrosis factor therapy, and tuberculosis: report of three challenging cases and literature review

INTRODUCTION

The era of biologic therapies has provided new options for the treatment of chronic plaque psoriasis. However, safety concerns have led to intensive screening and monitoring of patients receiving anti-tumor necrosis factor alpha (anti-TNF-alpha) agents.

METHODS

The authors describe the cases of three patients with moderate to severe psoriasis treated with anti-TNF agents, with challenging diagnostic and treatment aspects regarding tuberculosis (TB) infection, a serious adverse event associated with this type of treatment. The cases are discussed in the context of a comprehensive literature review describing the risk of TB associated with the use of TNF inhibitors. A critical review of the clinical trials that have tested the safety of these agents is also presented.

RESULTS

One patient, who tested negatively for latent TB infection (LTBI) during screening, developed active TB under adalimumab therapy. For two other patients the diagnosis and management of LTBI in relation to anti-TNF therapy represented a challenge. Although clinical trials involving the use of anti-TNF therapy for psoriasis haven't demonstrated a high TB incidence, active TB is continuously reported in association with this treatment.

CONCLUSIONS

Findings from clinical practice and the scientific literature indicate that anti-TNF therapies are associated with an increased risk of TB, and close monitoring of patients is needed.

Expert report on psoriasis: Spanish dermatologists' opinions on the use of biologic agents to manage moderate to severe psoriasis in adults

BACKGROUND

Although national guidelines on biologic agents for treating moderate to severe psoriasis in adults have been published in several countries, increased knowledge on the practical aspects of their implementation is required.

OBJECTIVE

The objective of this study was to survey Spanish dermatologists to determine their expert opinions on practical aspects of psoriasis treatment with biologics.

MATERIALS AND METHODS

An online survey was sent to 309 dermatologists who belong to the Spanish Psoriasis Group and/or the Spanish Academy of Dermatology and Venereology (AEDV). The questionnaire was designed specifically for the study and included items on various aspects of the treatment of psoriasis in clinical practice. Six coordinators in different geographic areas worked together to write the final expert report.

RESULTS

The response rate was 97% (300 returned questionnaires). The biologics preferred, or considered to be the best option (median score 4 out of 4 points) by respondents, were infliximab for its short-term efficacy (74% of the respondents) and rapid onset of action (78%); ustekinumab for convenience of administration (73%); and etanercept because of its suitability for cyclic treatment (71%), safety in long-term use (72%), and the possibility of temporary interruption of treatment under certain circumstances (76%). Etanercept was assigned the highest evaluations for safety and expected survival time (scored 5 on each item by 49% and 33% of the respondents, respectively). Thirty percent of the respondents considered that clinical guidelines contain important information for therapeutic management of psoriasis.

CONCLUSIONS

This study provides a unique perspective on the opinions of a large sample of dermatologists as regards current treatment of psoriasis with biologics in Spain.

Prolonged cyclosporine treatment of severe or recalcitrant psoriasis: descriptive study in a series of 20 patients

BACKGROUND

Although long-term cyclosporine administration may induce toxic effects, it may be the only option for the treatment of severe psoriasis. The objective of the present study was to retrospectively evaluate efficacy and safety of long-term cyclosporine treatment in a cohort of patients affected with moderate to severe psoriasis, recalcitrant or unresponsive to other treatments. Possible risk factors predicting an intolerance to cyclosporine were also investigated.

MATERIALS AND METHODS

Data were collected on psoriatic patients treated with cyclosporine for at least six months at our Psoriasis Outpatient Unit between January 2005 and September 2010. The primary measure for clinical efficacy was the PASI 75 response. Cyclosporine safety was assessed through the review of both laboratory tests and the adverse events registered during the treatment.

RESULTS

Twenty patients affected with plaque or erythrodermic psoriasis were evaluated. At Week 16, the PASI 75 response was achieved by 85% of patients. Adverse events occurred in eight patients (40%): four experienced an increase in serum creatinine levels to more than 30% of their pre-treatment values and four developed hypertension. Among these patients, five discontinued cyclosporine. Side effects resolved after stopping treatment.

CONCLUSIONS

Our findings suggest that long-term cyclosporine regimen can be justified in severe psoriasis not responsive to other treatments. When cyclosporine administration is required, obesity, pre-treatment controlled hypertension, increased age (>70 years), and metabolic syndrome should be taken into consideration, as a significant correlation with occurrence of cyclosporine-induced side effects has been found.