Treatment of Psoriasis with Secukinumab in Challenging Patient Scenarios: A Review of the Available Evidence

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part II: focus on elderly patients

INTRODUCTION

The management of moderate-to-severe forms of psoriasis is becoming a frequent concern in geriatric age due to the higher risk to develop treatment adverse events, logistic issues, vulnerability to immune-related diseases and cancer, presence of comorbidities and the risk of drug interactions. In this context, traditional systemic treatments are often contraindicated, and biologic drugs and small molecules seem to be a valuable option. However, data on their effectiveness and safety in elderly patients are scant.

AREAS COVERED

The aim of this review is to analyze the current literature in order to point out data on the efficacy and safety of biologic drugs and small molecules for the management of psoriasis in elderly patients in order to put the basis for universally shared treatment algorithm following available evidence. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the literature research.

EXPERT OPINION/COMMENTARY

Our review suggests biologics and small molecules as an effective and safe option for the management of moderate-to-severe forms of psoriasis in elderly patients.

Treating psoriasis in the elderly: biologics and small molecules

INTRODUCTION

Psoriasis prevalence in the elderly is growing. It is estimated that 15% of elderly psoriasis patients suffer from moderate-to-severe disease, thus requiring systemic treatments. However, conventional systemic agents' use is limited due to contraindications and drug-interactions. Conversely, biologics and small molecules seem to be a valuable option, although the geriatric psoriasis population is frequently excluded from trials and shared guidelines are lacking.

AREAS COVERED

Relevant English literature (trials, real-life studies, case series, and reviews) regarding biologics and/or small molecules in the elderly were searched for up to January 17, 2022.

EXPERT OPINION

Treatment of moderate-to-severe psoriasis in the elderly may be challenging due to multiple comorbidities, polypharmacy, and increased risk of infections and cancers. However, new targeted therapies offer the possibility to perform a tailored-tail management, considering comorbidities, drug-interactions, and frailties which characterize this class of patients. Several real-world data support biologics and small molecules' efficacy and safety in the elderly with mainly no significant difference as compared to young adults. Elderly psoriasis patients' expectations are as high as those of their younger counterparts. Hence, they deserve the best therapeutic options according to their peculiarities for a long-term psoriasis remission and an improved quality of life.

Hepatitis Virus Reactivation in Patients with Psoriasis Treated with Secukinumab in a Real-World Setting of Hepatitis B or Hepatitis C Infection

BACKGROUND AND OBJECTIVE

Biologics for psoriasis, especially anti-tumor necrosis factor-α therapies, may reactivate hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, as well in inactive carriers or patients with occult infection. However, some biologics, including anti-interleukin-17 therapies such as secukinumab, seem to be less likely to cause hepatitis reactivation. This study assessed the safety of secukinumab treatment in patients with psoriasis with HBV or HBC infection.

METHODS

This was a retrospective cohort study of patients with moderate-to-severe psoriasis treated with secukinumab at seven Italian centers. Patients serologically positive for one or more of the following viral hepatitis markers were included: HCV antibody (± HCV-RNA positivity) and/or hepatitis B surface antigen, and/or HBV core antibody and/or HBV surface antibody (± HBV-DNA positivity). Patients received secukinumab 300 mg subcutaneously at week 0/1/2/3/4 then every 4 weeks; prophylactic therapy before starting secukinumab was prescribed where indicated. The primary study endpoint was the reactivation of hepatitis viral infection, defined as conversion to HBV-DNA or HCV-RNA positivity, with or without elevation of transaminases.

RESULTS

Sixty patients (17 with concomitant psoriatic arthritis) were included. Thirteen subjects were hepatitis B surface antigen positive, 19 were HBV core antibody positive, and 30 were positive for the HCV antibody; however, all were HCV-RNA negative. After 53.5 ± 37.5 weeks of secukinumab therapy, hepatitis reactivation occurred in only one patient, who had a reactivation of both hepatitis B and hepatitis C. This patient had not undergone hepatitis B prophylaxis or hepatitis C treatment before secukinumab.

CONCLUSIONS

These real-world data support the safety of secukinumab in patients with positive markers of HBV or HCV infection, when administered together with dedicated prophylaxis.

Treatment with secukinumab for plaque psoriasis in patients with infectious comorbidities and latent tuberculosis: A multi-case report analysis

Three patients affected by plaque psoriasis and presenting with multiple infectious comorbidities and latent tuberculosis infection (LTBI) were initially managed with conventional DMARD therapy. After showing unsuccessful results, treatment with secukinumab was initiated without prophylactic isoniazid and soon led to favorable dermatological outcomes without the reactivation of tuberculosis infection.

Clinical Application of Pharmacogenetic Markers in the Treatment of Dermatologic Pathologies

Dermatologic pathologies are the fourth most common cause of non-fatal disease worldwide; however, they produce a psychosocial, economic, and occupational impact equal to or greater than other chronic conditions. The most prevalent are actinic keratosis, followed by basal-cell carcinoma, in a lesser proportion acne vulgaris, psoriasis, and hidradenitis suppurativa, among others, and more rarely dermatitis herpetiformis. To treat actinic keratosis and basal-cell carcinoma, 5-fluorouracil (5-FU) 0.5% is administered topically with good results, although in certain patients it produces severe toxicity. On the other hand, dapsone is a drug commonly used in inflammatory skin conditions such as dermatitis herpetiformis; however, it occasionally causes hemolytic anemia. Additionally, biologic drugs indicated for the treatment of moderate-to-severe psoriasis and hidradenitis suppurativa have proved to be effective and safe; nevertheless, a small percentage of patients do not respond to treatment with biologics in the long term or they are ineffective. This interindividual variability in response may be due to alterations in genes that encode proteins involved in the pathologic environment of the disease or the mechanism of action of the medication. Pharmacogenetics studies the relationship between genetic variations and drug response, which is useful for the early identification of non-responsive patients and those with a higher risk of developing toxicity upon treatment. This review describes the pharmacogenetic recommendations with the strongest evidence at present for the treatments used in dermatology, highlighting those included in clinical practice guides. Currently, we could only find pharmacogenetic clinical guidelines for 5-FU. However, the summary of product characteristics for dapsone contains a pharmacogenetic recommendation from the United States Food and Drug Administration. Finally, there is an enormous amount of information from pharmacogenetic studies in patients with dermatologic pathologies (mainly psoriasis) treated with biologic therapies, but they need to be validated in order to be included in clinical practice guides.

Influence of Genetic Polymorphisms on Response to Biologics in Moderate-to-Severe Psoriasis

Psoriasis is a chronic inflammatory skin pathology of autoimmune origin and unknown etiology. There are various therapies for treating it, including a wide range of biopharmaceuticals indicated in moderate-to-severe psoriasis. Depending on their therapeutic target, they are classified as tumor necrosis factor inhibitors (anti-TNF) or cytokine inhibitors (interleukin-12, 23, and 17 antagonists). Although they have proved effective and safe, in clinical practice, many patients show a short- and long-term suboptimal response and even varying degrees of toxicity. This variability in response may be influenced by genetic factors, such as polymorphisms in the genes involved in the pathological environment, metabolism or mechanism of action of the drug that could affect the effectiveness and toxicity of biological therapies. This review assesses pharmacogenetic studies of the impact of genetic factors on response to biopharmaceuticals and toxicity in patients diagnosed with moderate-to-severe psoriasis. The results suggest that polymorphisms detected in the HLA genes, in genes that encode cytokines (TNF, IL genes, TNFAIP3), transporters (PDE3A-SLCO1C1, SLC12A8), receptors (TNFRSF1B, CD84, FCGR2A and FCGR3A, IL17RA, IL23R, TLR genes, PGLYRP4) and associated proteins (TNFAIP3, LY96, TIRAP, FBXL19), as well as other genes implicated in the pathogenesis of psoriasis (CDKAL1, CARD14, PTTG1, MAP3K1, ZNF816A, GBP6, CTNNA2, HTR2A, CTLA4, TAP1) can be used in the future as predictive markers of treatment response and/or toxicity with biological therapies in patients diagnosed with moderate-to-severe psoriasis, tailoring treatment to the individual patient.

Two cases of refractory erythrodermic psoriasis effectively treated with secukinumab and a review of the literature

Erythrodermic psoriasis (EP), which accounts for 1 to 2.25% of all psoriatic cases, typically occurs in patients with poor control of existing psoriasis. Secukinumab yields rapid and sustained improvements of signs and symptoms in patients with plaque psoriasis. Currently, clinical data on the treatment of EP with secukinumab are scarce. We describe two adult patients with severe EP, including one male and one female who were both ineligible for or resistant to acitretin or methotrexate treatment and had additional diseases. The patients underwent treatment with secukinumab using the standard regimen. After 4 weeks of treatment, a 75% reduction in the Psoriasis Area and Severity Index score (PASI 75) was achieved in both patients. Secukinumab was well tolerated and was continued for at least 32 weeks of treatment. We report the clinical use of secukinumab in the treatment of EP and review its potential role in the management of this severe condition.

Secukinumab: A Review in Moderate to Severe Pediatric Plaque Psoriasis

Subcutaneous secukinumab (Cosentyx^®) is a recombinant, fully human, immunoglobulin (Ig) G1κ monoclonal antibody targeted against interleukin (IL)-17A, a proinflammatory cytokine involved in the pathogenesis of psoriasis. Secukinumab is approved in the EU and the USA for the treatment of moderate to severe plaque psoriasis in pediatric patients aged ≥ 6 years. In pivotal phase III trials in pediatric patients aged 6 to < 18 years, both low (75-150 mg) and high (75-300 mg) doses of secukinumab were significantly better than placebo and numerically better than etanercept at week 12 in terms of the proportion of patients achieving ≥ 75% improvement from baseline in Psoriasis Area and Severity Index and significantly better than placebo and etanercept in terms of the proportion of patients achieving an Investigator's Global Assessment score of 0 or 1. The clinical efficacy of secukinumab observed during the first 12 weeks of treatment was maintained over the longer term. Treatment with secukinumab improved health-related quality of life and was generally well tolerated. In conclusion, secukinumab represents a valuable new addition to the limited treatment options available for children and adolescents with moderate to severe plaque psoriasis.

Therapeutic challenges in managing pediatric psoriasis

Background

Each year, 20,000 patients aged <10 years are diagnosed with psoriasis. Pediatric-onset psoriasis has many similarities to adult-onset disease, and previous studies suggest that the incidence might be increasing in both populations.

Objective

The challenges that arise when treating patients with psoriasis, especially those age <12 years, are summarized, as well as the limited available treatment options for treating pediatric patients with psoriasis and the evidence supporting each of them.

Methods

Recently published guidelines by the American Academy of Dermatology and the National Psoriasis Foundations, as well as guidelines published by the German Society of Dermatology, provide considerable insight in managing patients who have this condition. The latest studies on pediatric psoriasis treatment were reviewed, including recent and current clinical trials with U.S. Food and Drug Administration approved and nonapproved medications, case reports, case series, and reviews. The authors also reviewed American and European guidelines, as well as recommendations from expert panels.

Results

Currently, only six medications are approved by the U.S. Food and Drug Administration for the treatment of pediatric psoriasis: three biologics and three topical. Many off-label topical treatments have been used in pediatric psoriasis, with variable effectiveness and safety profiles. Data from adult clinical trials, as well as case reports and series from pediatric patients, suggest that other biologic medications are effective for pediatric psoriasis.

Conclusion

Many questions remain unanswered, leaving clinicians facing multiple challenges when encountering pediatric patients with psoriasis. This summation will help provide an overview of current on- and off-label medications for pediatric psoriasis. Pediatric clinical trials should be implemented to obtain data that can result in expanding the therapeutic spectrum for this population, parallel to their adult counterparts.

Secukinumab monotherapy successfully treated severe refractory type V (atypical juvenile) pityriasis rubra pilaris: A case report and literature review

Pityriasis rubra pilaris (PRP) is a rare heterogeneous group of papulosquamous inflammatory disorders with unknown etiology. PRP is often resistant to many conventional therapies which has made more challenging on treatment. More recently, several studies have shown encouraging clinical results of secukinumab in the treatment of PRP in adult, but no studies have explored its effects in children. We herein report a 7-year-old boy with severe type V PRP responded rapidly to secukinumab monotherapy (150 mg once weekly) when conventional therapies have failed. The patient showed rapid and dramatic improvement of erythema, palmoplantar hyperkeratosis, scaling, and itching within only 5 weeks, with no adverse effects. Secukinumab could be considered as a treatment option for refractory PRP in children, as recently reported in adult.

Risk of tuberculosis reactivation with interleukin (IL)-17 and IL-23 inhibitors in psoriasis - time for a paradigm change

Tuberculosis is an infectious disease with a major global impact, ranked in the top 10 mortality causes worldwide. In an immunocompetent individual, the host defence mechanisms control Mycobacterium tuberculosis infection and induce the latent form of the disease. However, in the presence of diseases or therapies, which exert an immunosuppressive effect, latent tuberculosis can be re-activated. Psoriasis is an immune-mediated, inflammatory disease, and its treatment has rapidly evolved over the last few years. It has long been recognized that the tumour necrosis factor (TNF)-α inhibitors are associated with increased risk of reactivation of latent tuberculosis infection. Thus, international guidelines have been suggesting tuberculosis screening before starting the treatment with all biological agents since then. In addition, the institution of chemoprophylaxis in the presence of latent tuberculosis and the annual screening for tuberculosis thereafter have also been indicated. However, anti-tuberculosis treatments can have significant side-effects and there are currently several contraindications to their use. The risk benefit of starting anti-tuberculous treatment should be carefully weighed up. The emergence of new biological drugs for the treatment of psoriasis, such as interleukin (IL)-17 and IL-23 inhibitors, has reignited the subject of tuberculosis reactivation as it is possible that IL-17 and 23 blockade do not carry the same risk of TB reactivation as TNF-α inhibitors. Although preclinical studies have shown that cytokines IL-17 and IL-23 have a possible role against infection with M. tuberculosis, data from clinical trials and post-marketing surveillance with drugs that inhibit these cytokines appear to suggest that they are not crucial to this response. In this article, we review the available data on tuberculosis reactivation after the treatment of psoriasis with IL-17 and IL-23 inhibitors, and its possible impact on the way we currently manage latent tuberculosis infection before or after starting treatment with these new drugs.