Adherence to biologics in patients with psoriasis

Biosimilars for the treatment of psoriasis: a narrative review

The introduction of systemic biologic therapies marked a significant advancement in the treatment of moderate to severe psoriasis. However, the high cost associated with these treatments has considerably restricted their widespread utilization. The expiration of biologic patents has allowed the development of biosimilars - medications that are highly similar to approved biologics. Biosimilars hold the promise of reducing treatment costs, thereby enhancing patient access to biologic therapies and contributing to the sustainability of healthcare spending. Nonetheless, the unique regulatory pathways for biosimilars introduce uncertainties regarding their application in real-world psoriasis care. Adoption and regulation of biosimilars differ considerably across countries, reflecting diverse approaches and priorities within global healthcare systems. Potential variations between biosimilars and their originator biologics raise questions about their comparative effectiveness and safety. Current evidence supporting biosimilars for psoriasis treatment is largely based on a limited number of randomized controlled trials (RCTs), with a notable lack of robust real-world evidence. As more biosimilars enter the market, evaluating their use in real-world settings is crucial to identify any differences in effectiveness and safety compared to originators or to enhance their uptake by improving the perceptions of physicians and patients. This review explores the opportunities and challenges presented by biosimilars and underscores the existing gaps in evidence regarding their use in psoriasis treatment.

Real-world outcomes following switching from anti-TNF reference products to biosimilars for the treatment of psoriasis

Tumor necrosis factor (TNF) inhibitors improved clinical outcomes for patients with psoriasis but are limited by their high cost. There are several biosimilar options approved for the treatment of psoriasis which provides a lower-cost alternative and the potential to increase treatment availability for both biologically naïve and bioexperienced patients. Numerous phase III randomized controlled trials (RCTs) have investigated the effects of switching from biologics to biosimilars; biosimilars had comparable safety and efficacy to their reference products. Real-world evidence may provide complementary information on the expected performance of biosimilars. In this literature review, we analyzed data from real-world studies on switching from biologics for psoriasis to their biosimilars. Effectiveness and safety profiles were comparable when switching from biologics to biosimilars of adalimumab, etanercept, and infliximab. These studies are limited by their sample sizes, duration of follow-up, and single-arm designs without control groups. Based on available real-world evidence, patients may safely and effectively undergo switching to biosimilar therapies for the treatment of psoriasis.

Persistence of second-line biologics in psoriasis after first-line biologic failure: a nationwide cohort study from the French health insurance database (SNDS)

BACKGROUND

Many biologics are available for psoriasis and have been compared in real-life studies based on their persistence (i.e. time between initiation and discontinuation). However, after first-line biologic failure, data are lacking on the choice of second-line biologic among the four available classes [tumour necrosis factor inhibitors (TNFi); interleukin (IL)-12/IL-23 inhibitor (IL-12/IL-23i); IL-17 inhibitors (IL-17i); and IL-23 inhibitors (IL-23i)].

OBJECTIVES

To compare the long-term persistence of available second-line biologics in psoriasis according to prior exposure.

METHODS

This nationwide cohort study involved the administrative healthcare database of the French health insurance scheme linked to a hospital discharge database. Participants were adults with psoriasis, defined as having at least two prescriptions of a topical vitamin D derivative within a 2-year period, with initiation of a second-line biologic between 1 January 2015 and 31 December 2021. We included patients who initiated a second-line biologic directly after first-line discontinuation (i.e. without a 'washout' period). The end of follow-up was 30 June 2022. Discontinuation was defined as > 90 days without filling a prescription for the same treatment after the period covered by the previous prescription. Comparison of persistence by biologic class involved using propensity score-weighted Cox models (inverse probability treatment weighting) and adjustment of specific systemic nonbiologics (time-dependent variables).

RESULTS

We included 8693 patients [mean (SD) age 50 (14) years; 50.5% male]; 2824 (32.5%) started TNFi, 1561 (18.0%) IL-12/IL-23i, 2707 (31.1%) IL-17i and 1601 (18.4%) IL-23i. Overall, 1- and 3-year persistence rates were 60% and 30%, respectively. After weighting and adjustment, persistence was longer with IL-12/IL-23i [weighted hazard ratio (HRw) 0.68, 95% confidence interval (CI) 0.62-0.76)], IL-17i (HRw 0.70, 95% CI 0.64-0.78) and IL-23i (HRw 0.36, 95% CI 0.31-0.42) than TNFi, except after first-line IL-17i treatment, with no difference between IL-12/IL-23i, IL-17i and TNFi second-line persistence. Persistence was longer with IL-23i as a second-line treatment than IL-12/IL-23i (HRw 0.53, 95% CI 0.44-0.63) and IL-17i (HRw 0.51, 95% CI 0.44-0.60), regardless of first-line treatment, with no difference seen between IL-12/IL-23i and IL-17i (HRw 0.97, 95% CI 0.87-1.09).

CONCLUSIONS

This real-life study suggests the longer persistence of IL-23i than TNFi, IL-17i and IL-12/IL-23i as second-line treatment for psoriasis. Persistence rates for all biologics remained low at 3 years.

Healthcare Costs Among Patients with Psoriasis Treated with Ixekizumab Versus Secukinumab in Real-World Settings Over 24 Months

OBJECTIVE

The aim of this study was to compare healthcare costs between ixekizumab (IXE)-treated and secukinumab (SEC)-treated patients with psoriasis over a 24-month follow-up period in the United States.

METHODS

Patients with psoriasis diagnosis were identified from IBM Watson Health MarketScan^® Research Databases; those with one or more claim for index drug (IXE or SEC) between March 1, 2016 and October 31, 2019 were included. Included patients were ≥ 18 years old and had continuous enrollment with medical and pharmacy benefits ≥ 6 months before and ≥ 24 months after index date. Patients were classified as IXE or SEC users based on drug received at index. Per patient per month (PPPM) all-cause, psoriasis-related, and index drug costs for IXE and SEC users were estimated over 24 months of follow-up. Institute for Clinical and Economic Review (ICER) discount factors were applied to adjust pharmacy costs. Index drug costs were additionally adjusted for adherence. Inverse probability of treatment weighting was used to address cohort imbalances. Chi-square/t tests were used to compare IXE versus SEC users; p value < 0.05 was considered statistically significant.

RESULTS

Overall, 1461 patients (IXE users, n = 471; SEC users, n = 990) were included. IXE versus SEC users had higher weighted PPPM all-cause, psoriasis-related, and index drug costs (p ≤ 0.001). IXE versus SEC users had comparable ICER-adjusted mean PPPM all-cause costs (US$4172 ± 3349 vs US$3978 ± 2619; p = 0.227) and psoriasis-related costs (US$2950 ± 1332 vs US$2899 ± 1152; p = 0.447). After applying ICER and adherence adjustments, index drug costs were similar between IXE and SEC users (US$3794 ± 1822 vs US$3766 ± 1973; p = 0.795).

CONCLUSIONS

All-cause and psoriasis-related costs were comparable between IXE and SEC users after ICER adjustments; index drug costs were similar after ICER and adherence adjustments.

Real-World Biologic Adherence, Persistence, and Monotherapy Comparisons in US Patients with Psoriasis: Results from IBM MarketScan® Databases

INTRODUCTION

Limited real-world data are available comparing multiple biologics on their adherence, persistence, and the use of concomitant biologics in the treatment of moderate-to-severe psoriasis in clinical practice. The objective was to compare persistence of and adherence to ixekizumab (IXE) treatment, as monotherapy or with concomitant medication, versus patients receiving other commonly prescribed biologics.

METHODS

Patients who newly initiated IXE, adalimumab (ADA), etanercept (ETN), secukinumab (SEC), or ustekinumab (UST) in IBM MarketScan^® databases with diagnosis of psoriasis were identified. Treatment comparisons on medication persistence, adherence, and monotherapy were based on balanced samples after inverse probability of treatment weighting (IPTW).

RESULTS

A higher proportion of patients receiving IXE had had previous biologic therapies (50.3%) versus other biologics (ADA: 9.1%, ETN: 10.9%, SEC: 33.9%, UST: 19.7%). Patients treated with IXE showed statistically (p < 0.001) greater persistence than patients treated with SEC, ADA, UST, or ETN at both 1-year follow-up and up to 3 years of follow-up. Adherence for patients treated with IXE was significantly (p < 0.001) higher compared to ADA, ETN, and UST at both 1-year follow-up and up to 3 years of follow-up. There was no significantly higher adherence in patients treated with IXE compared to those treated with SEC at 1-year follow-up, but IXE had higher adherence than SEC (p < 0.05) at 1-3 year follow-up. IXE showed longer time on monotherapy than ADA (p < 0.001), ETN (p < 0.001), SEC (p < 0.05), and UST (p < 0.001) for both 1-year and 1-3 year follow-up. Sensitivity analyses on persistence, adherence, and monotherapy with further model adjustments after IPTW confirmed the findings.

CONCLUSIONS

Patients treated with IXE were more persistent on and adherent to treatment and remained on monotherapy longer compared to those on all other commonly prescribed biologics combined or with individual biologics.

Drug Adherence and Persistence of Patients with Moderate to Severe Psoriasis Treated with Biologic Medications in a US Commercially Insured Population

BACKGROUND

Adalimumab (ADA), certolizumab pegol (CER), etanercept (ETA), guselkumab (GUS), ixekizumab (IXE), secukinumab (SEC), and ustekinumab (UST) are biologic medications approved in the USA for the treatment of moderate to severe psoriasis. We examined drug adherence and persistence of patients with moderate to severe psoriasis who initiated these seven biologic medications.

METHODS

Adult patients with ≥1 pharmacy/medical claim for any of the seven psoriasis medications and ≥1 diagnosis of psoriasis in the previous 6 months between July 1, 2014 and June 30, 2019 were selected from the IBM MarketScan® Commercial Claims and Encounters Database. The index date was defined as the date of the first prescription fill. Patients were required to have continuous health plan enrollment during the 6 months prior to their index date and ≥9 months after. Patients were grouped into seven study cohorts based upon their index biologic medication. Adherence was measured using the proportion of days covered (PDC) and defined by a PDC ≥80%. Adherence and persistence with index biologic medications were examined during fixed follow-up periods of 3, 6, and 9 months, with a subpopulation analysis carried out among patients with 12 months of follow-up.

RESULTS

Among psoriasis patients with ≥9 months of continuous enrollment included in the study population, the number of those who initiated each biologic medication was 10,324 for ADA, 431 for CER, 3,092 for ETA, 821 for GUS, 1,766 for IXE, 4,132 for SEC, and 5,441 for UST. The mean age at the time of initiating biologic treatment was 46.9 years. During the 9-month follow-up period, the proportions of adherent patients (i.e., PDC ≥80%) were numerically higher among those treated with UST (59.9%) and GUS (56.9%), followed by those treated with SEC (46.1%), IXE (45.5%), ADA (44.7%), ETA (33.9%), and CER (22.0%). The proportions of patients who were persistent with their index biologic medication during the 9-month follow-up period were numerically higher among those treated with UST (70.1%) and GUS (67.8%), followed by those treated with IXE (47.3%), SEC (46.9%), ADA (28.7%), CER (14.8%), and ETA (10.7%).

CONCLUSIONS

In this large healthcare claims database analysis of psoriasis patients treated with seven different biologic medications, adherence was numerically higher among those treated with UST or GUS. UST and GUS were also associated with numerically greater persistence.

Remote pharmaceutical care for patients with rheumatoid arthritis and psoriasis

BackgroundAccess to drugs with hospital-restricted dispensation, such as those for patients with rheumatoid arthritis or psoriasis, is regulated by healthcare policy. These drugs have the greatest cost-effective impact on the healthcare system. This is why a model for Pharmaceutical Care based on follow-up teleconsultations was defined in our hospital to improve patient well-being. Objective To evaluate clinical changes on patients when our remote Pharmaceutical Care model is applied and describe the work carried out by pharmacists when applying it. Setting Pharmacy Department of a Hospital in Barcelona, Spain. Method Cross-sectional observational study of the remote Pharmaceutical Care model developed by Clinical Pharmacists. All patients diagnosed with psoriasis or rheumatoid arthritis who were receiving active treatment with Hospital/Specialist only drugs, during the period from May to December 2018, were included. Main outcome measures The corresponding healthcare activity was recorded and to determine the utility of the model, the clinical response to treatment of patients included in the study was recorded. Results The implementation of teleconsultation is statistically related to the biological treatment response of patients with psoriasis (p = 0.006) and rheumatoid arthritis (p = 0.019). In those patients the healthcare activity of calculating and/or recording clinical variables of effectiveness/safety is statistically associated to biological treatment response (65.62% vs 35%, p = 0.015 and 73.14% vs 53.26%, p = 0.003). Conclusions The implementation of the model described lends added value to traditional pharmacotherapeutic management of biological treatments in patients with rheumatoid arthritis and psoriasis since response is improved but patient well-being is not diminished.

Comparison of Real-World Treatment Patterns Among Psoriasis Patients Treated with Ixekizumab or Adalimumab

BACKGROUND

There is lack of real-world treatment pattern comparison data between ixekizumab and adalimumab which are approved for the treatment of moderate-to-severe plaque psoriasis.

OBJECTIVE

To compare real-world treatment patterns among psoriasis patients initiating ixekizumab or adalimumab in the United States.

METHODS

Psoriasis patients with ≥1 claim for ixekizumab or adalimumab between March 1, 2016, and May 31, 2018, were identified (index date = date of first ixekizumab or adalimumab claim) from the IBM Watson Health MarketScan^® databases. Patients were required to be continuously enrolled for ≥12 months before the index date and followed for a minimum of 6 months until inpatient death, enrollment end, or study end, whichever occurred first. Treatment persistence, adherence, discontinuation, restart, and switching were analyzed. Inverse probability of treatment weighting and multivariable regression modeling were employed to address cohort imbalances and estimate the adjusted risk of non-persistence, discontinuation, and switching, and the odds of adherence.

RESULTS

A total of 646 ixekizumab and 3668 adalimumab users were included and followed for a mean of 14.0 and 16.5 months, respectively. Compared to adalimumab, ixekizumab was associated with 19% lower risk of non-persistence (hazard ratio [HR]=0.81, 95% confidence interval [CI]: 0.69-0.95), 26% lower risk of discontinuation (HR=0.74, 95% CI: 0.62-0.88), and 28% lower risk of switching (HR=0.72, 95% CI: 0.57-0.91). Ixekizumab users had higher odds of medication possession ratio ≥80% (odds ratio [OR]=1.36, 95% CI: 1.10-1.69) but similar odds by proportion of days covered ≥80% (OR=1.22, 95% CI: 0.98-1.53).

CONCLUSION

Psoriasis patients treated with ixekizumab demonstrated longer persistency, higher adherence and were less likely to discontinue or switch treatment compared to adalimumab users. However, while patients achieving highly adherent threshold significantly differed by MPR ≥80%, it did not by PDC ≥80%; hence, further analysis using fixed-length follow-up is required.

Nonadherence to Treatment and Patient-Reported Outcomes of Psoriasis During the COVID-19 Epidemic: A Web-Based Survey

PURPOSE

The COVID-19 epidemic has caused difficulties in continuous treatment for patients with chronic diseases and resulted in nonadherence to treatment and adverse health outcomes. This study aimed to investigate the associations of nonadherence to treatment with patient-reported outcomes of psoriasis during the COVID-2019 epidemic.

METHODS

A cross-sectional study among Chinese patients with psoriasis was conducted through a web-based questionnaire survey during 25 Feb 2020 and 6 Mar 2020. Demographic and clinical data, nonadherence to treatment, and patient-reported outcomes were collected. The outcomes included deterioration of the disease condition, perceived stress, and symptoms of anxiety and depression. Logistic regression was used to investigate the associations.

RESULTS

A total of 926 questionnaires were collected. A total of 634 (68.5%) reported nonadherence to treatment, and worse adherence was found among patients receiving systemic treatment (adjusted odds ratio [AOR]: 2.67; 95% CI: 1.40-5.10) and topical treatment (AOR: 4.51; 95% CI: 2.66-7.65) compared to biological treatment. Nonadherence to treatment (less than two weeks and more than two weeks) was significantly associated with deterioration of psoriasis (aOR: 2.83 to 5.25), perceived stress (AOR: 1.86 to 1.57), and symptoms of anxiety (AOR: 1.42 to 1.57) and depression (AORs: 1.78). Subgroup analysis by treatment showed consistent results in general.

CONCLUSION

Nonadherence to treatment was associated with the aggravation of psoriasis conditions, perceived stress, and symptoms of anxiety and depression.

Targeting the IL-23/IL-17 Pathway in Psoriasis: the Search for the Good, the Bad and the Ugly

New promising treatments have been developed for psoriasis that target different parts of the interleukin (IL)-23/IL-17 pathway. This approach is believed to be more disease specific, and sparing the T helper 1 pathway might prevent serious long-term adverse events. Moreover, superior Psoriasis Area and Severity Index improvements are observed, which has redefined treatment goals in psoriasis. The new molecules can be divided into different categories, according to the target: blocking agents can target the upstream cytokine IL-23 or the downstream IL-17. In the latter, a variety of targets exist, such as the ligands IL-17A and IL-17F, or a combination thereof, or a subunit of the receptor, IL-17RA. Each target seems to have its own set of advantages and pitfalls, which will impact the treatment decision in clinical practice. In this review, we summarize the current knowledge on the different inhibitors of the IL-23/IL-17 pathway. Furthermore, we briefly discuss the role of IL-17 in other diseases and comorbidities. Finally, we discuss how comprehensive knowledge is needed for the prescribing physician in order to make the most appropriate therapeutic choice for each individual patient.