IL-23 Inhibitors for Psoriasis

What Can IBD Specialists Learn from IL-23 Trials in Dermatology?

BACKGROUND AND AIMS

The advent of biologic drugs revolutionised the treatment of many chronic inflammatory diseases in rheumatology, dermatology, and gastroenterology. The introduction of different targeted agents closely followed the increase in knowledge of pathogenic mechanisms. The identification of IL-23 as a master regulator of 'pathogenic' inflammation and the consequent efficacy of IL-23 blocking agents were first proofed in psoriasis and then in other inflammatory diseases such as psoriatic arthritis and Crohn's disease.

METHODS

We reviewed all available results from anti-Il-23 clinical trials for psoriasis, focusing on data of IBDologists' interest. Regarding guselkumab, we analysed data from phase III clinical trials VOYAGE1, VOYAGE2, and NAVIGATE. For risankizumab, we reported efficacy and safety results from UltIMMa-1, UltIMMa-2, and IMMvent clinical trials, and tildrakizumab was evaluated by analysing data from reSURFACE1 and reSURFACE2 studies.

RESULTS

Data from all the clinical trials that we reported showed both the efficacy of all three anti-IL-23 drugs in psoriasis and the safety of this class; in particular, no gastrointestinal side effects were observed in those studies. IL-23 blockers have shown promising short- and long-term results in psoriasis, with a major safety profile and no negative interactions with gastrointestinal system.

CONCLUSIONS

Anti-IL-23 indication for psoriatic arthritis is very recent and for IBD is still to come. Therefore, dermatologists are accumulating long-term experience with these drugs, both in clinical trials and in real-world evidence, which can help gastroenterologists in the management of IBD patients.

Tildrakizumab: A Review in Moderate-to-Severe Plaque Psoriasis

Tildrakizumab (tildrakizumab-asmn in the USA) [Ilumetri^®; Ilumya™] is a humanized monoclonal antibody (mAb) that selectively targets the p19 subunit of interleukin (IL)-23, thereby inhibiting the IL-23/IL-17 axis, the signalling pathway primarily implicated in the immunopathogenesis of psoriasis. Administered subcutaneously, it is approved for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy (e.g. in the EU and Australia) and those who are candidates for systemic therapy or phototherapy (in the USA). In the pivotal phase III reSURFACE 1 and 2 trials, tildrakizumab was superior to placebo and efficacious compared with etanercept, in terms of the proportion of patients achieving a response [≥ 75% improvement from baseline in Psoriasis Area and Severity index score (PASI 75) and a Physician's Global Assessment score of 0/1] at week 12. Response rates peaked at week 22 and the vast majority of patients achieving PASI 75 at week 28 maintained this response after a total of 3 years of treatment in the reSURFACE trials and their ongoing open-label extension studies. In addition, patients with a partial or no response to etanercept at week 28 benefitted from switching to the highest approved dose of tildrakizumab in the reSURFACE 2 trial and its ongoing extension. Treatment with tildrakizumab improved health-related quality of life and was generally well tolerated, both in the short- and longer-term. Tildrakizumab thus expands the range of useful therapeutic options for patients with moderate-to-severe plaque psoriasis, particularly those with an inadequate response to phototherapy and conventional systemic agents.

Guselkumab: A Review in Moderate to Severe Plaque Psoriasis

Guselkumab (Tremfya^®) is a human immunoglobulin G1 λ (IgG1λ) monoclonal antibody (mAb) that blocks the interleukin-23 (IL-23)-mediated signalling pathway and is the first in its class to be approved in adults with moderate to severe plaque psoriasis in several countries, including the USA and EU. In the VOYAGE trials, guselkumab was superior to placebo and to adalimumab at week 16 in terms of the proportion of patients achieving an Investigator Global Assessment (IGA) score of 0/1 and ≥ 90% improvement from baseline in Psoriasis Area and Severity index score (PASI 90 response), with benefits of guselkumab over adalimumab maintained at week 24. To date, the beneficial effects of guselkumab treatment in these trials were maintained for up to 2 years. Inadequate responders to ustekinumab who were then randomized to guselkumab in NAVIGATE showed better responses than those randomized to ustekinumab between weeks 28-40, with a significantly greater mean number of visits at which patients had IGA 0/1 and ≥ 2-grade improvement in IGA score, as well as higher proportions of patients achieving PASI 90 and PASI 100 at week 52. Treatment with guselkumab improved health-related quality of life (HR-QOL) and patient-reported outcomes in all trials and was generally well tolerated. Guselkumab, administered by subcutaneous injection, is a useful new option for patients with moderate to severe plaque psoriasis.