Efficacy of guselkumab in subpopulations of patients with moderate‐to‐severe plaque psoriasis: a pooled analysis of the phase III VOYAGE 1 and VOYAGE 2 studies

Choosing the right biologic treatment for moderate-to-severe plaque psoriasis: the impact of comorbidities

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease often associated with several comorbidities, such as psoriatic arthritis, inflammatory bowel disease, obesity, diabetes mellitus or cardiovascular diseases, infections, or cancer, among others. With the progressive aging of the population, a growing number of patients with psoriasis can be expected to present multiple comorbidities. Currently, there is a wide range of biological treatments available for moderate to severe psoriasis, including tumor necrosis alpha (TNF) inhibitors, IL12/23 inhibitor, IL17 inhibitors, and IL23 inhibitors.

AREAS COVERED

This review aims to describe the specific characteristics of these drugs in relation to psoriasis comorbidities, in order to facilitate decision-making in clinical practice.

EXPERT OPINION

Some of the biological treatments can influence comorbidities, in some cases even improving them. Therefore, comorbidities are a key factor when deciding on one biological treatment over another. The development of new drugs is expanding the therapeutic arsenal for psoriasis. A high level of expertise in the field with a detailed knowledge of the characteristics of every drug is imperative to provide personalized medicine.

Guselkumab in Patients with Scalp Psoriasis: A post hoc Analysis of the VOYAGE 2 Phase III Randomized Clinical Trial

Scalp psoriasis affects approximately 80% of patients with psoriasis and can negatively impact their quality of life. This post hoc analysis of the VOYAGE 2 Phase III randomized clinical trial evaluated scalp response to guselkumab treatment and its association with skin response and patient-reported outcomes. The study included patients with moderate-to-severe plaque psoriasis and baseline scalp psoriasis who were initially randomized to receive guselkumab. Patients were divided into 3 groups based on their achievement of a Psoriasis Area and Severity Index 90 response at week 28: responder continuation, non-responder continuation and responder withdrawal. In all 3 groups, mean Psoriasis Area and Severity Index head and scalp-specific Investigator's Global Assessment scores improved through week 28. In the responder withdrawal group, these scores worsened after treatment withdrawal at week 28, but remained stable through week 48 in both continuation groups. Trends in Dermatology Life Quality Index and Psoriasis Symptoms and Signs Diary itch scores mirrored those of mean scalp-specific Investigator's Global Assessment scores through week 48. Within-subject correlations were 0.83 between scalp-specific Investigator's Global Assessment and Psoriasis Area and Severity Index head scores and 0.78 between scalp-specific Investigator's Global Assessment and Psoriasis Symptoms and Signs Diary itch scores. Through week 252, Psoriasis Area and Severity Index head scores remained stable in the responder continuation group, improved in the non-responder continuation group and rapidly improved by week 84 in the responder withdrawal group after retreatment.

Guselkumab-Treated Patients with Plaque Psoriasis Who Achieved Complete Skin Clearance for ≥ 156 Consecutive Weeks: A Post-Hoc Analysis From the VOYAGE 1 Clinical Trial

BACKGROUND

Treatment of moderate-to-severe plaque psoriasis with biologics, such as guselkumab, has demonstrated greater efficacy over traditional non-biologic treatments. However, given patient diversity, greater understanding of the relationship between patient characteristics, positive clinical outcomes, and long-term response to biologics is crucial for optimizing treatment choices.

MATERIALS AND METHODS

This post-hoc analysis of the 5-year VOYAGE 1 clinical trial compares baseline characteristics of patients maintaining a Psoriasis Area and Severity Index (PASI) score of 0 at all visits for ≥ 156 consecutive weeks (PASI = 0 group) with those that never achieve PASI = 0 (comparator group), using descriptive statistics and a multiple logistic regression model. Guselkumab plasma trough concentrations in both response groups were assessed from Weeks 4-156.

RESULTS

Of patients who started guselkumab treatment at Week 0 or at Week 16 after switching from placebo, 22.7% (112/494) maintained PASI = 0 for ≥ 156 consecutive weeks. Numerical differences in baseline characteristics, including age, obesity, diabetes, PASI score, disease duration, smoking status, and psoriatic arthritis comorbidity, were identified between the PASI = 0 group and comparator group. Plasma guselkumab levels were consistently higher in the PASI = 0 group. Multiple logistic regression analysis revealed absence of diabetes, lower Dermatology Life Quality Index score at baseline, and higher Week 4 guselkumab plasma concentration as significantly (p < 0.05) associated with the PASI = 0 group.

CONCLUSION

A substantial (22.7%) number of guselkumab-treated patients in the VOYAGE 1 clinical trial maintained complete skin clearance for a consecutive period of ≥ 156 weeks. Factors associated with this outcome may suggest clinical benefits of holistic treatment approaches.

TRIAL REGISTRATION

NCT02207231.

Successful long-term guselkumab treatment of severe plaque psoriasis in patients with class III obesity: A case series

Data from real-world studies and clinical trials have documented the long-term efficacy and safety of guselkumab in patients with moderate-to-severe psoriasis. Limited data are available on the long-term use of guselkumab in morbidly obese individuals with severe psoriasis. Here, we present data on the outcome of three patients with class III obesity (body mass index (BMI) of ≥40 kg/m2) with severe plaque psoriasis treated with 100 mg guselkumab. At baseline, mean BMI was 46.5 ± 5.4 kg/m2 and mean PASI was 46.0 ± 18.5 and all patients were biologic naïve. After 12 weeks of guselkumab treatment, mean PASI decreased to 9.7 ± 4 and to 4.0 ± 1.7 at 28 weeks. After 1 year, two patients achieved complete remission and one patient had PASI of 6 (achieving remission by week 140). All three patients are still in complete remission. Our real-life results in specific patients burdened with class III obesity naïve to biologic treatment show excellent long-term psoriasis outcome with guselkumab.

Clinical features, therapeutic choice and response by phototype in psoriasis: analysis of the French PsoBioTeq cohort

BACKGROUND

Little is known about phototype and the response to systemic treatment in psoriasis.

OBJECTIVES

To assess the characteristics of psoriasis, the therapeutic choice and its efficacy according to phototype.

METHODS

We included patients from the PsoBioTeq cohort initiating a first biologic. Patients were classified according to their phototype. The evaluation included disease characteristics, choice of the initial biologic and therapeutic response at 12 months based on 90% improvement from baseline in Psoriasis Area and Severity Index (PASI 90) and Dermatology Life Quality Index (DLQI) 0/1.

RESULTS

Of the 1400 patients included, 423 (30.2%), 904 (64.6%) and 73 (5.2%) were in the phototype I-II, III-IV and V-VI groups, respectively. The V-VI group had a higher initial DLQI, and more frequently initiated ustekinumab. Patients in the V-VI group maintained the initial biologic prescribed as did the other phototype groups, even though the proportion of patients reaching PASI 90 and DLQI 0/1 at 12 months was lower in this group than the other groups.

CONCLUSIONS

Patient phototype seems associated with quality of life and choice of the initial biologic in psoriasis. The phototype V-VI group less frequently switched treatments than did the other groups when the response was not efficient.

Nail psoriasis dynamics during biologic treatment and withdrawal in patients with psoriasis who may be at high risk of developing psoriatic arthritis: a post hoc analysis of the VOYAGE 2 randomized trial

BACKGROUND

Nail psoriasis is a common, physiologically, and psychologically disruptive, and yet often under-treated manifestation of psoriasis. The objectives of this analysis were to investigate the trajectory of nail psoriasis, a risk factor for psoriatic arthritis (PsA), with guselkumab vs adalimumab treatment followed by withdrawal, and determine characteristics associated with nail response in patients treated with guselkumab.

METHODS

This post hoc analysis of the phase III trial VOYAGE 2 included patients with moderate-to-severe plaque psoriasis and baseline nail involvement. Nail Psoriasis Severity Index (NAPSI) and Psoriasis Area and Severity Index (PASI) were analyzed through week 48 in patients randomized to guselkumab or adalimumab. Multiple logistic regression analyzed factors associated with NAPSI 0/1 at week 24/week 48 following guselkumab treatment. In a separate analysis, patients were stratified by prior biologic experience.

RESULTS

Overall, 272 vs 132 patients receiving guselkumab vs adalimumab had nail psoriasis at baseline. Lower baseline NAPSI and week 16 PASI were associated with achieving NAPSI 0/1 at week 24 (NAPSI, odds ratio 0.685 [95% confidence interval: 0.586, 0.802]; week 16 PASI, 0.469 [0.281, 0.782]) and week 48 (NAPSI, 0.784 [0.674, 0.914]; week 16 PASI, 0.557 [0.331, 0.937]) with guselkumab. Previous biologic experience did not impact NAPSI response. Following treatment withdrawal at week 28, mean NAPSI was maintained in the guselkumab arm (week 24 1.7, week 48 1.9) and increased slightly in the adalimumab arm (week 24 1.4, week 48 2.3). Mean PASI increased across both treatment arms.

CONCLUSIONS

Higher skin efficacy at week 16 was associated with better nail responses during guselkumab treatment. Nail psoriasis improvements reflected skin improvements. Following guselkumab withdrawal, nail response was maintained longer than skin response. Future studies should investigate whether such improvements in nail response reduce patients' risk of later PsA development.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02207244. Registered July 31, 2014.

The Effectiveness of Guselkumab by BMI Category Among Patients with Moderate-to-Severe Plaque Psoriasis in the CorEvitas Psoriasis Registry

INTRODUCTION

Prior studies have demonstrated guselkumab improves disease activity and patient-reported outcomes (PROs) among patients with moderate-to-severe plaque psoriasis. However, the real-world effectiveness of guselkumab across different subgroups [e.g., body mass index (BMI) categories] remains an area of active research.

METHODS

This study included patients enrolled in the CorEvitas Psoriasis Registry between July 18, 2017 and March 10, 2020 who had moderate-to-severe psoriasis [Investigator's Global Assessment (IGA) score ≥ 3], initiated guselkumab at a registry visit (index date), and had a follow-up registry visit after persistent guselkumab therapy for 9-12 months. Patients were stratified into three BMI categories: obese (≥ 30 kg/m2), overweight (25- < 30 kg/m2), and underweight/normal weight (< 25 kg/m2). Response rates and mean changes for disease activity outcomes and PROs at follow-up were assessed within each BMI category.

RESULTS

Of the 180 patients included in the study, 101 (56%) were obese, 52 (29%) were overweight, and 27 (15%) were underweight/normal weight. Among the obese, overweight, and underweight/normal weight patients, 57%, 58%, and 72%, respectively, achieved an IGA score of 0/1 after 9-12 months of persistent guselkumab treatment. An IGA score of 0 was achieved by 33%, 35%, and 48% of obese, overweight, and underweight/normal weight patients, respectively. A 90% improvement in the Psoriasis Area and Severity Index was achieved by 46%, 46%, and 56% in these respective subgroups. Mean improvements in disease activity and PRO scores were similar among BMI subgroups.

CONCLUSION

The results of this real-world study showed improvements in disease severity and several PRO scores within all BMI categories among patients with moderate-to-severe psoriasis treated with guselkumab. These unadjusted findings suggest that obese and overweight patients have comparable absolute improvements to those with lower BMI; however, they may be less likely to achieve relative endpoints. Additional analyses are needed to fully characterize this relationship.

Guselkumab More Effectively Neutralizes Psoriasis-Associated Histologic, Transcriptomic, and Clinical Measures than Ustekinumab

Given the key role of the IL-23/Th17 axis in the pathogenesis of moderate-to-severe plaque psoriasis, several specific inhibitors of the p19 subunit of IL-23 have been approved to treat this chronic inflammatory disease. Clinical data indicate that guselkumab, one such selective IL-23 inhibitor, achieves greater clinical efficacy compared with ustekinumab, which inhibits both IL-12 and IL-23 via binding their shared p40 subunit. To understand mechanisms underlying the enhanced efficacy observed with the p19 subunit of IL-23-specific inhibition, we explored cellular and molecular changes in skin of psoriasis patients treated with ustekinumab or guselkumab and in ustekinumab inadequate responders (Investigator's Global Assessment of psoriasis score ≥ 2) subsequently treated with guselkumab (ustekinumab→guselkumab). Skin biopsies were collected pretreatment and posttreatment to assess histologic changes and molecular responses in ustekinumab- and guselkumab-treated patients. Serum cytokines and skin transcriptomics from the subset of ustekinumab→guselkumab-treated patients were also analyzed to characterize differential treatment effects. Ustekinumab and guselkumab demonstrated differential effects on secretion of pathogenic Th17-related cytokines induced by IL-23 in in vitro assays, which suggest guselkumab is a more potent therapeutic agent. Consistent with these findings, guselkumab elicited a significantly greater reduction in cellular and molecular psoriasis-related disease indicators than ustekinumab. In ustekinumab→guselkumab patients, suppression of serum IL-17A and IL-17F levels and neutralization of molecular scar and psoriasis-related gene markers in skin were significantly greater compared with patients continuing ustekinumab. This comparative study demonstrates that guselkumab inhibits psoriasis-associated pathology, suppresses Th17-related serum cytokines, and normalizes the psoriasis skin gene expression profile more effectively than ustekinumab.

Racial/ethnic differences in treatment efficacy and safety for moderate-to-severe plaque psoriasis: a systematic review

Biologic medications have revolutionized treatment of psoriasis; however, there remains uncertainty in which medications should be used to maximize efficacy based on race/ethnicity. The purpose was to determine if efficacy of biological medications differs based on race/ethnicity. A systematic review identified all clinical trials focused on biologic treatment outcomes from inception of database until March 5th, 2021. Included studies provided data on racial/ethnic differences in biologic skin clearance efficacy using the Psoriasis Area and Severity Index (PASI) and "clear/almost clear" scores. There were 1220 studies identified, and 24 included in the review. The races/ethnicities included were Asian (n = 2740), White (n = 9745), Black (n = 138), and Latino (n = 728). Ixekizumab provided the highest "clear/almost clear" score (90.7%, 89.4%) and PASI 75 (98.8%, 96.6%) for Asian and Latino patients, respectively. Guselkumab had the highest "clear/almost clear" score for White (86.8%) patients, while Black patients had highest "clear/almost clear" (75.0%) and PASI 75 (91.7%) scores to brodalumab. Limitations included lack of studies reporting outcome data based on race/ethnicity and lack of patients of color within psoriasis clinical trials. For treatment of plaque psoriasis, there is evidence of differences in efficacy of biologics improving clinical disease severity between different races or ethnicities.

Effectiveness, survival and safety of guselkumab attending to basal characteristics in moderate-to-severe psoriatic patients: a cohort study

Background: Psoriasis is a chronic inflammatory disease which can impact quality of life. In the past decade multiple biologic treatments have been released with encouraging results. Guselkumab is a monoclonal antibody targeting IL-23p19. Multiple randomized clinical trials have demonstrated its efficacy in psoriasis, but response differences among patient subpopulations have not been extensively reported. Furthermore, patients in real life are often non-eligible for clinical trials and their responses may differ from pivotal studies. Methods: This is a retrospective, observational study of real clinical practice of patients receiving guselkumab treatment in Spain. Patients treated with guselkumab were included between February 2019 to December 2021. This study evaluates the potential differential effect of baseline demographic and disease characteristics on therapeutic responses to guselkumab. We measured effectiveness and survival by the psoriasis area and severity index, the dermatology life quality index as well as Kaplan meier curves, respectively. Categorical and quantitative variables are reported with frequencies, and with mean and standard deviation, respectively. Differences between groups in psoriasis area and severity index and dermatology life quality index, were calculated using a mixed-effects analysis. Survival was calculated using Kaplan meier curves and log-rank tests. Results: A total of 87 patients were included. In this study, our objective was to evaluate the effectiveness, safety and survival of guselkumab attending to demographic characteristics. No differences in psoriasis area and severity index or dermatology life quality index baseline values or therapeutic responses were noted at 52 weeks of follow-up among all the subgroups analysed (age, sex, psoriasis duration, body mass index, and comorbidities). A difference in drug survival was only seen between gender groups. Conclusions: Our research has demonstrated the consistency of guselkumab effectiveness across patient subgroups. No baseline features affected the effectiveness or drug survival of guselkumab, except for lower drug survival in female patients.

The imbalance between Type 17 T-cells and regulatory immune cell subsets in psoriasis vulgaris

Psoriasis vulgaris is a common inflammatory disease affecting 7.5 million adults just in the US. Previously, psoriasis immunopathogenesis has been viewed as the imbalance between CD4⁺ T-helper 17 (Th17) cells and regulatory T-cells (Tregs). However, current paradigms are rapidly evolving as new technologies to study immune cell subsets in the skin have been advanced. For example, recently minted single-cell RNA sequencing technology has provided the opportunity to compare highly differing transcriptomes of Type 17 T-cell (T17 cell) subsets depending on IL-17A vs. IL-17F expression. The expression of regulatory cytokines in T17 cell subsets provided evidence of T-cell plasticity between T17 cells and regulatory T-cells (Tregs) in humans. In addition to Tregs, other types of regulatory cells in the skin have been elucidated, including type 1 regulatory T-cells (Tr1 cells) and regulatory dendritic cells. More recently, investigators are attempting to apply single-cell technologies to clinical trials of biologics to test if monoclonal blockade of pathogenic T-cells will induce expansion of regulatory immune cell subsets involved in skin homeostasis.

Clinical Efficacy and Safety of Psoriasis Treatments in Patients with Concomitant Metabolic Syndrome: A Narrative Review

Metabolic syndrome (MetS) is well recognized as a frequent comorbidity of psoriasis with important implications for efficacy and safety of psoriasis treatment. The presence of concomitant MetS is associated with decreased efficacy response to biologic treatment for psoriasis in observational studies. In post hoc analyses of clinical trial data, the anti–IL-23p19 antibody tildrakizumab appears to maintain efficacy in patients compared to those without MetS; no published subgroup analyses by MetS status are yet available for other biologics. However, there is some evidence that obese patients have decreased psoriasis treatment efficacy with biologics with certain mechanisms of action relative to overweight patients. This confounds interpretation of the effect of MetS due to the association between MetS and body weight. Because of the association between MetS and cardiovascular risk, treatment of psoriasis in patients with concomitant MetS requires special consideration for cardiovascular safety and attention to potential for exacerbation of MetS and related conditions, including nonalcoholic fatty liver disease. Additional studies are needed to clarify the risks for treatment failure and cardiovascular safety concerns in patients with psoriasis and concomitant MetS.

[Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2-Management of Special Populations, Patients With Comorbid Conditions, and Risk

BACKGROUND AND OBJECTIVES

Since its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents.

METHODOLOGY

The consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted.

RESULTS

The present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.

Sustained and improved guselkumab response in patients with active psoriatic arthritis regardless of baseline demographic and disease characteristics: pooled results through week 52 of two phase III, randomised, placebo-controlled studies

OBJECTIVES

To evaluate the efficacy through 52 weeks of guselkumab, an interleukin 23-p19 subunit inhibitor, in subgroups of pooled psoriatic arthritis (PsA) patients from the DISCOVER-1 and DISCOVER-2 trials defined by baseline patient characteristics.

METHODS

Adults with active PsA despite standard therapies were enrolled in DISCOVER-1 (≥3 swollen and ≥3 tender joints, C reactive protein (CRP) level ≥0.3 mg/dL) and DISCOVER-2 (≥5 swollen and ≥5 tender joints, CRP ≥0.6 mg/dL, biological-naïve). Randomised patients received 100 mg guselkumab at weeks 0, 4, and then every 4 or 8 weeks (Q4W/Q8W) or placebo. Guselkumab effects on joint (ACR20/50/70), skin (IGA 0/1, IGA 0), patient-reported outcome (Health Assessment Questionnaire Disability Index/Functional Assessment of Chronic Illness Therapy-Fatigue) and disease severity (minimal disease activity/PsA Disease Activity Score low disease activity) endpoints were evaluated by patient sex, body mass index, PsA duration, swollen/tender joint counts, CRP level, percent body surface area with psoriasis, Psoriasis Area and Severity Index score, and conventional synthetic disease-modifying antirheumatic drug use at baseline.

RESULTS

Baseline patients characteristics in DISCOVER-1 (N=381) and DISCOVER-2 (N=739) were well balanced across randomised groups. At week 24, 62% (232/373) and 60% (225/375), respectively, of guselkumab Q4W-treated and Q8W-treated patients pooled across DISCOVER-1 and DISCOVER-2 achieved the primary endpoint of ACR20 response versus 29% (109/372) of placebo-treated patients. Guselkumab treatment effect at week 24 was observed across patient subgroups. Within each patient subgroup, response rates across all disease domains were sustained or increased at week 52 with both guselkumab regimens.

CONCLUSIONS

Guselkumab Q4W and Q8W resulted in robust and sustained improvements in PsA signs and symptoms consistently in subgroups of patients defined by diverse baseline characteristics.

TRIAL REGISTRATION NUMBERS

NCT03162796, NCT03158285.

Secukinumab dosing every two weeks demonstrated superior efficacy compared with dosing every four weeks in patients with psoriasis weighing 90 kg or more: Results of a randomised controlled trial

BACKGROUND

Obesity is a common comorbidity of psoriasis and can attenuate response to biologic treatment.

OBJECTIVES

To investigate the efficacy, safety and tolerability of secukinumab 300 mg every 2 weeks (Q2W) vs. secukinumab 300 mg every 4 weeks (Q4W) in patients with a higher body weight.

METHODS

In this multicentre, double-blind, parallel-group trial, 331 patients with moderate-to-severe chronic plaque psoriasis weighing ≥90 kg were randomised to receive secukinumab 300 mg Q2W or secukinumab 300 mg Q4W. Patients who did not achieve PASI90 at Week 16 on the Q4W regimen were reallocated to remain on the Q4W regimen or up-titrate to Q2W.

RESULTS

At Week 16, Q2W dosing (N=165) led to significantly higher PASI90 responses vs. Q4W [N=166; 73.2% vs. 55.5%, one-sided p-value=0.0003, odds ratio estimate (95% confidence intervals): 2.3 (1.4, 3.8). At Week 52, higher efficacy responses were maintained in the Q2W arm (N=165) vs. Q4W (N=83); PASI75: 88.9% vs. 74.8%; PASI90: 76.4% vs. 52.4%, PASI100: 46.7% vs. 27.3%; IGA 0/1: 75.9% vs. 55.6% and DLQI 0/1: 66.1% vs. 48.8%. PASI90 non-responders at Week 16 who up-titrated to Q2W (N=31) showed higher efficacy responses at Week 32 (16 weeks post-up-titration, PASI90: 38.7% vs. 16.5%) vs. those who remained on Q4W (N=40). Safety results were comparable across treatment arms and consistent with the established secukinumab safety profile.

CONCLUSIONS

Secukinumab 300 mg Q2W demonstrated superior and sustained efficacy compared with Q4W in moderate-to-severe plaque psoriasis patients weighing ≥90 kg. PASI90 non-responders derived additional benefits from up-titration to a Q2W regimen. (NCT03504852).

Comorbid obesity and history of diabetes are independently associated with poorer treatment response to biologics at 6 months: A prospective analysis in Corrona Psoriasis Registry

BACKGROUND

Psoriasis is associated with comorbid systemic metabolic disease.

OBJECTIVE

To assess possible associations of comorbid obesity, history of diabetes, hypertension, and hyperlipidemia with response to biologic treatment at 6 months among patients in CorEvitas' Psoriasis Registry.

METHODS

Participants included 2924 patients initiating biologic therapy (tumour necrosis factor inhibitors [TNFi], interleukin [IL]-17i, IL-12/23i, or IL-23i) with baseline and 6-month follow-up visits available. Logistic regressions resulted in adjusted odd ratios (OR) and 95% confidence intervals (CI) for achievement of response in select outcomes for those with obesity and history of diabetes, hypertension, and hyperlipidemia relative to those without each.

RESULTS

Overall, obesity reduced by 25% to 30% odds of achieving PASI75 (OR, 0.75; 95% CI, 0.64-0.88) and PASI90 (OR, 0.70; 95% CI, 0.59-0.81). History of diabetes reduced odds of achieving PASI75 by 31% (OR, 0.69; 95% CI, 0.56-0.85) and PASI90 by 21% (OR, 0.79; 95% CI, 0.63-0.98). Obesity was associated with lower response to TNFi and IL-17i classes. Independent of obesity, diabetes was associated with poorer outcomes when on IL-17i therapy and hypertension, to a lesser extent, when on the TNFi class. No significant associations were found in the hyperlipidemia group.

LIMITATIONS

The study assessed only short-term effectiveness and small sample sizes limited the power to detect differences.

CONCLUSION

Assessment of comorbid disease burden is important for improved likelihoods of achieving treatment response with biologics.

Effect of diet and weight loss on the severity of psoriasis

Psoriasis is one of the most common chronic inflammatory skin diseases, constituting a significant health and socioeconomic problem. Despite numerous therapeutic options, the results of treatment often remain insufficient. This may be due to the lack of compliance with medical prescriptions and patients’ limited knowledge of their disease. Psoriatic patient's skin well-being is affected by many factors, including lifestyle. The course of the disease is affected by obesity, improper diet, and stimulants. Often these factors coexist. Excessive weight gain in psoriasis can be caused by a decrease in physical activity, caused by feelings of social stigma, coexistence of psoriatic arthritis, depression, and increased alcohol consumption. Several studies have confirmed that the average fat, protein, and calorie content in the diet of a patient with psoriasis are above the recommended norms. On the other hand, adhering to a low calorie, reducing diet results in a clinically significant improvement in the Psoriasis Area Severity Index (PASI) and patients’ quality of life (i.e., reduction of Dermatology Life Quality Index [DLQI]). Weight reduction caused by diet and exercise reduces the severity of skin lesions, even in people who have not achieved improvement after general treatment. Therefore, it is important to educate the patient about the nature of the disease at the very beginning of treatment. Patients with moderate to severe forms of the disease are predisposed to the development of cardiovascular diseases, obesity, diabetes, and anxiety. That is why plaque psoriasis requires a comprehensive treatment and a holistic approach to the patient.

Effectiveness and safety of guselkumab for the treatment of psoriasis in real-world settings at 24 weeks: A retrospective, observational, multicentre study by the Spanish Psoriasis Group

BACKGROUND

Data on the effectiveness and safety of a drug in real-world clinical practice complement the evidence from clinical trials, which are carried out in a different setting. Little has been published on the effectiveness and safety of guselkumab in the treatment of psoriasis in clinical practice.

OBJECTIVES

To assess the effectiveness and safety of guselkumab at 24 weeks in patients with moderate to severe plaque psoriasis in routine clinical practice.

METHODS

Retrospective, multicentre study of adult patients with moderate to severe plaque psoriasis treated with guselkumab for at least 24 weeks in Spain.

RESULTS

We studied 343 patients, 249 of whom were followed for 24 weeks. By week 24, the mean (SD) Psoriasis Area and Severity Index (PASI) had decreased from 11.1 (7.3) to 1.7 (2.8) (-9.3; [-10.2;-8.4]), 85.9% of the patients had achieved PASI score of 4 or less and 77.9% a PASI score of 2 or less. In terms of relative PASI response, 59.4% of the patients achieved a PASI-90 response and 49.0% a PASI-100 response. On multivariate analysis, 2 factors reduced the probability of a PASI of 2 or less at 24 weeks: a BMI ≥30 (OR, 0.44; 95% CI, 0.22-0.88) and a greater previous exposure to biologic therapy (OR, 0.69; 95% CI, 0.56-0.84]). Adverse events were rare (9.9%) and led to withdrawal from treatment in only 9 patients (2.6%) by the end of the follow-up period.

CONCLUSION

The results of this study confirm the high efficacy and safety of guselkumab indicated by the clinical trial data. In clinical practice, the absolute PASI score appears to be a better marker of response to treatment than the relative value.

Impact of previous biologic use and body weight on the effectiveness of guselkumab in moderate-to-severe plaque psoriasis: a real-world practice

Background:

Real-life data on patients with psoriasis treated with guselkumab are few and are needed to compare with trial-based data. We investigated the effect of clinical factors on real-world effectiveness of guselkumab.

Methods:

This multicentre study retrospectively included 135 patients with psoriasis treated with guselkumab from June 2018 until November 2020. Effectiveness was assessed using the degree of improvement in the Psoriasis Area and Severity Index (PASI) scores at baseline and after 4, 12, 20, 28, and 36 weeks. Predictors of effectiveness were also evaluated.

Results:

At week 36, 67% of the patients achieved PASI 75. Multivariate logistic regression analysis revealed that heavier patients were less likely to achieve PASI 75 at week 4 than patients with lower body weights. Fewer patients exposed to only one biologic achieved PASI 75 at weeks 4, 20, 28, and 36 [odds ratio (OR) = 0.08 (95% CI, 0.01–0.48), 0.21 (95% CI, 0.05–0.74), 0.04 (95% CI, 0.00–0.35), and 0.07 (95% CI, 0.00–0.68), respectively] than biologic-naïve patients. Patients previously treated with more than one biologic were less likely to achieve PASI 75 at weeks 12, 20, 28, and 36 [OR = 0.05 (95% CI, 0.01–0.22), 0.03 (95% CI, 0.01–0.16), 0.00 (95% CI, 0.00–0.03), and 0.00 (95% CI, 0.00–0.044), respectively] than biologic-naïve patients. Patients with previous anti-interleukin (IL)-17 exposure, rather than tumour necrosis factor-α and IL-12/23 inhibitors, had lower PASI improvements to guselkumab than biologic-naïve patients at weeks 12, 20, and 28 [OR = 0.19 (95% CI, 0.03–0.90), 0.10 (95% CI, 0.02–0.55), and 0.03 (95% CI, 0.00–0.29), respectively].

Conclusions:

The effectiveness of guselkumab was compromised in a real-world setting. Delayed onset of therapeutic response was noted in heavier patients. Biologic exposure, the number of previously used biologics, and previous exposure to IL-17 inhibitors were clinical predictors of a reduced response to guselkumab. Physicians may share this information with patients to make treatment decisions.

Increased Skin Clearance and Quality of Life Improvement with Brodalumab Compared with Ustekinumab in Psoriasis Patients with Aggravating Lifestyle Factors

Introduction

Obesity, smoking, and alcohol consumption are prevalent in psoriasis patients and have been associated with increased disease severity and reduced treatment adherence and response. This post hoc analysis of pooled data from the phase 3 AMAGINE-2 and -3 trials compared the efficacy of brodalumab versus ustekinumab in psoriasis patients with aggravating and potentially treatment-confounding lifestyle risk factors.

Methods

This post hoc analysis evaluated complete skin clearance, as measured by a 100% reduction of Psoriasis Area and Severity Index (PASI100) and quality of life (QoL), as measured by a Dermatology Life Quality Index (DLQI) score of 0/1, by the presence of risk factors (obesity, tobacco or alcohol use). A competing risk model assessed cumulative incidence over 52 weeks with outcomes of PASI100 or inadequate response.

Results

This analysis included 929 patients (brodalumab 210 mg, n = 339; ustekinumab, n = 590) with moderate-to-severe psoriasis. At week 52, odds ratios (95% confidence intervals [CIs]) for complete clearance with brodalumab versus ustekinumab were 2.50 (1.14–5.46, P = 0.0186), 4.64 (2.80–7.69, P < 0.0001), 2.06 (1.25–3.40, P = 0.0045), and 2.55 (0.55–11.91, P = 0.2117) in patients with no, one, two, or three risk factors, respectively. Corresponding odds ratios (ORs) (95% CIs) for DLQI 0/1 with brodalumab versus ustekinumab were 1.72 (0.78–3.79, P = 0.1883), 2.49 (1.54–4.02, P < 0.0002), 1.57 (0.97–2.54, P = 0.0666), and 2.07 (0.45–9.57, P = 0.3438). The 52-week cumulative incidence of patients achieving PASI100 was consistently higher for brodalumab versus ustekinumab, regardless of number of risk factors (P < 0.0001 for one or two risk factors and P = 0.0029 for three risk factors).

Conclusions

Higher levels of complete skin clearance and QoL were achieved and maintained with brodalumab versus ustekinumab in patients with moderate-to-severe psoriasis, regardless of the presence of lifestyle risk factors.

Clinical Trial Registration

AMAGINE-2 (NCT01708603); AMAGINE-3 (NCT01708629).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00618-5.

Efficacy of guselkumab versus secukinumab in subpopulations of patients with moderate-to-severe plaque psoriasis: results from the ECLIPSE study

PURPOSE

Guselkumab, an interleukin (IL)-23 inhibitor, effectively treats moderate-to-severe plaque psoriasis.

MATERIALS AND METHODS

ECLIPSE, was a Phase 3, multicenter, 56-week, double-blinded, active-comparator study of guselkumab vs. secukinumab (IL-17A inhibitor) in patients with moderate-to-severe psoriasis. Patients were treated with guselkumab 100 mg (n = 534) or secukinumab 300 mg (n = 514) through week 44. Efficacy (at least a 90% and 100% improvement from baseline in Psoriasis Area and Severity Index [PASI 90 and PASI 100], Investigator's Global Assessment [IGA] 0/1, and IGA 0) was analyzed across subpopulations defined by baseline: age (<45, 45 to <65, and ≥65 years old), body weight, body mass index (BMI), psoriasis disease severity (body surface area, disease duration, PASI, and IGA), psoriasis by body regions (head, trunk, upper and lower extremities), and prior psoriasis medication history at week 48.

RESULTS

Overall, 1048 patients were randomized. At week 48, numerically greater proportions of patients achieved PASI 90, PASI 100, IGA 0/1, and IGA 0 with guselkumab vs. secukinumab regardless of baseline age, body weight, BMI, disease severity, body region, and prior medication. The largest differences were in patients ≥65 years old and patients weighing >100 kg.

CONCLUSIONS

Guselkumab treatment provided greater efficacy vs. secukinumab at week 48 in most subpopulations of patients with psoriasis.

Evaluation of short-term (16-week) effectiveness and safety of guselkumab in patients with psoriasis: A prospective real-life study on the Chinese population

Real-life data on guselkumab in psoriasis are limited and not available in China hitherto. This study aimed to evaluate the short-term effectiveness and safety of guselkumab in patients with psoriasis under Chinese real-life conditions and to explore the effect of guselkumab on CD4⁺ CD25⁺ Foxp3⁺ regulatory T cells (Tregs). A Chinese prospective and real-life study involving patients with psoriasis in Dermatology Hospital of Southern Medical University, Guangzhou, China from April to September 2020 was conducted. A total of 45 patients with psoriasis were finally enrolled in the study. Psoriasis Area Severity Index (PASI) 90 and 100 responses at week 16 were achieved by 88.6% and 45.5% of patients, respectively. The analysis of PASI response in different subgroups showed no statistically significant difference. Univariate logistic regression analysis revealed that at week 16, none of the variables were associated with decreasing PASI 90 response, whereas age at onset of disease was a predictor of PASI 100 response. Dynamic detection of CD4⁺ CD25⁺ Foxp3⁺ Tregs frequency from peripheral blood suggested a stable maintained trend in terms of guselkumab treatment duration. No severe adverse events occurred during the follow-up period. This study confirmed the short-term effectiveness and safety of guselkumab, as well as its good tolerance against psoriasis, in the Chinese population. Guselkumab treatment maintains levels of Tregs in patients with psoriasis.

Anti-Interleukin-17 Therapy of Severe Psoriatic Patients Results in an Improvement of Serum Lipid and Inflammatory Parameters' Levels, but Has No Effect on Body Composition Parameters

BACKGROUND: Psoriasis is frequently accompanied by metabolic syndrome. Effect of anti-tumor necrosis factor therapies on increases in body weight is well-known. Data on the effects of interleukin-17 inhibitors are limited. Authors determined the effect of anti-interleukin-17 therapies on the body composition and serum lipid and inflammatory parameters among severe psoriatic patients. METHODS: Thirty-five severe psoriatic patients were enrolled. Twenty-two received secukinumab and 13 received ixekizumab as their 2nd-or 3rd-line biological treatment. Before treatment initiation and 6 months later, laboratory examinations measuring metabolic and inflammatory panels and body composition analyses were performed. RESULTS: After 6 months, a significant reduction was observed in psoriasis area severity index (p < 0.001) from 18 to 0, in c-reactive protein (p < 0.001) from 6.6 to 4.00 mg/L, in low-density lipoprotein-cholesterol (p = 0.004) from 3.69 to 3.19 mmol/L, and an improvement in high-density lipoprotein-cholesterol (p = 0.022) from 1.31 to 1.40 mmol/L. Median baseline body mass index was 32.80 kg/m². The body composition parameters did not show any significant changes. CONCLUSIONS: Anti-interleukin-17 therapy of severe psoriatic patients does not cause significant changes in body composition parameters. Improvements in the lipid and inflammatory parameters might have a beneficial effect on patients’ cardiometabolic status. This effect might be detectable in high-risk obese psoriatic patients.

Practical recommendations for systemic treatment in psoriasis according to age, pregnancy, metabolic syndrome, mental health, psoriasis subtype and treatment history (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 1)

Background

Impressive progress in new therapeutic options has been made for psoriasis. Treatments include topical steroids, phototherapy, conventional, synthetic disease‐modifying drugs and an expanding list of biologics.

Objective

The primary objective of this work was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis).

Methods

Evidence‐based recommendations were formulated using a quasi‐Delphi methodology after a systematic search of the literature and a consensus procedure involving 8 psoriasis experts.

Results

In this part, the use of systemic treatment in different age groups, during pregnancy, in metabolic syndrome, in patients with mental health problems, in different psoriasis subtypes and in previously systemically treated patients treatment is discussed.

Conclusion

Guidance on therapeutic choice in specific clinical situations in psoriasis is provided in order to facilitate the decision‐making in clinical practice.

Maintaining Clinical Freedom Whilst Achieving Value in Biologics Prescribing: An Integrated Cross-Specialty Consensus of UK Dermatologists, Rheumatologists and Gastroenterologists

BACKGROUND

Biologics are now key drugs in the management of immune-mediated inflammatory diseases. However, the increasingly complex biologics environment and growing cost pressures in the UK have led to variability in drug commissioning and inequity of patient access across regions.

OBJECTIVES

Our objectives were to provide consensus recommendations for enhancing the current situation in biologic prescribing in the UK by balancing clinical freedom with equitable distribution of biologics given the limited availability of resources.

METHODS

A modified Delphi approach was used to reach integrated, cross-specialty consensus among dermatologists, rheumatologists and gastroenterologists practising within the English National Health Service (NHS).

RESULTS

We describe the concepts of clinical freedom and clinical judgement and demonstrate how, together with patient choice, they can be exercised in the context of biologic prescribing in the NHS. We highlight that in England, local variations occur that are at odds with National Institute for Health and Care Excellence (NICE) guidance; these variably limit the degree to which clinicians can exercise clinical freedom and impact on equity of patient access to treatments. We define factors encompassing a drug's value and identify challenges to the measurement and interpretation of this concept, which can raise barriers to the freedom of clinical choice and appropriate prescribing decisions allowing practices of holistic and personalised medicine. Cross-specialty consensus recommendations on ensuring equitable access to biologics in the NHS while protecting appropriate and individualised drug selection for patients are provided. We have also provided strategies for improving physician-commissioner communication to harmonise equity of patient access to biologics across England and improve patient outcomes. Commentary from patient advisory groups indicates that they welcome our exploration that value does not equal cost and agree that there should be an emphasis on shared decision making, which requires the clinician to practice clinical freedom by aligning the patient's needs and preferences with available treatment choices.

CONCLUSIONS

This consensus highlights the need to strike a balance between clinical freedom and short-term cost restrictions to support equitable resource distribution within the English NHS. Consideration of these recommendations may help to harmonise local, regional and national services and balance equity of patient access to biologic treatments with excellence in the NHS.

Clinical Utility of Guselkumab in the Treatment of Moderate-to-Severe Plaque Psoriasis

Psoriasis is a chronic immune-mediated disease involving complex interaction of T cells and keratinocytes. The comprehensive pathogenesis of psoriasis is not fully understood but the IL-23/Th17 axis is a central pathway in driving disease development. Guselkumab is the first treatment of moderate-to-severe psoriasis that specifically targets the p19 subunit of IL-23. The benefit of guselkumab has been established by a number of clinical trials including demonstration of greater long-term efficacy in recent comparator trials. This review addresses the results of head-to-head trials (ECLIPSE, IXORA-R, and POLARIS) that compared guselkumab to secukinumab, ixekizumab, and fumaric acid esters. The previously demonstrated long-term efficacy of guselkumab has been corroborated by many recently published studies. The effective and safe profile, convenient dosing, and improved quality of life in patients make gulselkumab a viable first-line treatment option for moderate-to-severe psoriasis.

JAK Inhibitors for Treatment of Psoriasis: Focus on Selective TYK2 Inhibitors

Despite advances in the treatment of psoriasis, there is an unmet need for effective and safe oral treatments. The Janus Kinase-Signal Transducer and Activator of Transcription (JAK-STAT) pathway plays a significant role in intracellular signalling of cytokines of numerous cellular processes, important in both normal and pathological states of immune-mediated inflammatory diseases. Particularly in psoriasis, where the interleukin (IL)-23/IL-17 axis is currently considered the crucial pathogenic pathway, blocking the JAK-STAT pathway with small molecules would be expected to be clinically effective. However, relative non-specificity and low therapeutic index of the available JAK inhibitors have delayed their integration into the therapeutic armamentarium of psoriasis. Current research appears to be focused on Tyrosine kinase 2 (TYK2), the first described member of the JAK family. Data from the Phase II trial of BMS-986165-a selective TYK2 inhibitor-in psoriasis have been published and clinical results are encouraging, with a large Phase III programme ongoing. Further, the selective TYK2 inhibitor PF-06826647 is being tested in moderate-to-severe psoriasis in a Phase II clinical trial. Brepocitinib, a potent TYK2/JAK1 inhibitor, is also being evaluated, as both oral and topical treatment. Results of studies with TYK2 inhibitors will be important in assessing the clinical efficacy and safety of these drugs and their place in the therapeutic armamentarium of psoriasis. This article reviews current data on the impact of JAK inhibitors in the treatment of adult patients with moderate-to-severe psoriasis.

Use of Guselkumab for the Treatment of Moderate-to-Severe Plaque Psoriasis: A 1 Year Real-Life Study

Little information is available from real-life studies evaluating the efficacy of guselkumab in moderate-to-severe psoriasis. In this real-life study, we retrospectively examined a database of 52 patients with moderate-to-severe psoriasis treated with guselkumab (100 mg, s.c.) and followed for 1 year. Disease severity and treatment response was assessed by the Psoriasis Area and Severity Index (PASI) at baseline and after 4, 12, 20, 28, 36, 44, and 52 weeks. Predictors of a PASI response were evaluated by univariate and multivariate regression. After 12 months, 84.2% of patients (mean age 51.3 ± 14.1 years) treated with guselkumab achieved a PASI score of <3. Furthermore, PASI score decreased from 20 ± 13.3 at baseline to 4.4 ± 4.7 and 2.7 ± 3.9 at 12 and 20 weeks, and PASI 75, 90, and 100 response was achieved in 84.2%, 78.9%, and 63.2% of patients respectively at 12 months. Stepwise multivariate regression analysis revealed that previous biological treatment and the presence of comorbidities were associated with poorer response between 28–44 weeks, however the presence of obesity per se was not associated with poorer response. Difficult-to-treat areas were also improved as early as 12 weeks following guselkumab. Guselkumab was observed to be effective and safe in patients with moderate-severe chronic psoriasis in a real world-setting.

Guselkumab in the treatment of moderate-to-severe plaque psoriasis

Recent advances in our understanding of the immunopathogenesis of psoriasis have resulted in novel therapeutic agents. IL-23, mainly produced by dendritic cells, maintains the differentiation of naive T cells to Th17 cells, the keystone effector cells in psoriasis. The clinical effectiveness of therapeutic agents targeting this cytokine has been demonstrated in moderate-to-severe plaque psoriasis. Guselkumab (Tremfya®, Janssen Biotech, Inc., PA, USA) is the first human antibody against the p40 subunit of the IL-23 receptor approved by the US FDA and the EMA for this indication in adult patients (2017). It has also been approved for treatment of psoriatic arthritis in Japan (April 2018). This article reviews the published data relating to the efficacy and safety of guselkumab for treatment of moderate-to-severe plaque psoriasis.

Treatment of psoriasis: janus kinases inhibitors and biologics for the interleukin-23/Th17 axis

With the discovery of the IL-23 / Th17 axis, the treatment of psoriasis has entered a new era. The aim of this study was to explore the progress of biologics and janus kinases (JAK) inhibitors targeting IL-23/Th17 axis in the treatment of psoriasis. review of English-language article was performed. Search terms included IL-17, IL-23, biologics, monoclonal antibodies, neutralizing antibodies, JAK, inhibitors, Psoriasis Area Severity Index and psoriasis. Data were selected from two phase 2 clinical trials; and nine phase 3 randomized, double-blind clinical trials; and other clinical trials. This review analyzes skin lesion clearance and major adverse reactions of 9 mAbs including mirikizumab and bimekizumab. At the same time, the research progress and prospects of three non-IgG small molecule biologics are analyzed too. This paper also compares the efficacy and limitations of biologics targeting the IL-23/Th17 axis with non-biologics acting on the JAK-signal transducer and activator of transcription pathway. The IL-17A/F inhibitors and non-IgG small molecule biologics that are being studied will bring a revolutionary development to the treatment of psoriasis. Topical application of JAK inhibitors can not only achieve the purpose of treating psoriasis, but also reduce the amounts of systemic medication, and reduces side effects. Each drug has its own indication, and the effect of the drug can be better achieved by selecting the indication for the drug.

Biologics switch in psoriasis

Aim: No guidelines exist for biologic switch in psoriasis after treatment failure. Although, switching between TNF-α antagonists has been reviewed, switching information about newer biologics is limited. Materials & methods: We did a thorough systematic review from 'PubMed' and 'Embase', which includes new biologics such as IL-12/IL-23 antagonists, IL-17A antagonists and IL-23 antagonists. Results & conclusion: New biologics such as IL-17 antagonist or IL-23 antagonist show greater responses in bio-experienced patients and could even be used for patients in whom previous treatments failed.

Efficacy and Safety of Biologics for Psoriasis and Psoriatic Arthritis and Their Impact on Comorbidities: A Literature Review

Psoriasis is a chronic inflammatory skin disease characterized by scaly indurated erythema. It impairs patients’ quality of life enormously. It has been recognized not only as a skin disease but as a systemic disease, since it also causes arthritis (psoriatic arthritis) and mental disorders. Furthermore, an association with cardiovascular events is indicated. With the advent of biologics, treatment of psoriasis dramatically changed due to its high efficacy and tolerable safety. A variety of biologic agents are available for the treatment of psoriasis nowadays. However, characteristics such as rapidity of onset, long-term efficacy, safety profile, and effects on comorbidities are different. Better understanding of those characteristic leads to the right choice for individual patients, resulting in higher persistence, longer drug survival, higher patient satisfaction, and minimizing the disease impact of psoriasis. In this paper, we focus on the efficacy and safety profile of biologics in psoriasis patients, including plaque psoriasis and psoriatic arthritis. In addition, we discuss the impact of biologics on comorbidities caused by psoriasis.

A modern approach to the treatment of plaque psoriasis

Psoriasis is a common chronic inflammatory skin disease which affects 0.5-1 % of children and 2-3 % of the adult population. In Croatia, 1.6 % of the population suffer from psoriasis. Distribution of the disease is bimodal, with the first peak at the age of 20-30, and the second at the age of 50-60. The etiopathogenesis of the disease is multifactorial, the key factors being genetic predisposition combined with immunological disorders, environmental factors and skin barrier damage. There are several clinical variants of the disease. The main signalling pathways in psoriasis include TNF-α, IL-23 and IL-17. Topical agents are used for the treatment of the mild form, and the systemic conventional therapy is used for the treatment of moderate to severe forms of the disease. In cases where's no response, or intolerance or contraindications are present, new targeted medications are to be administered. Development in the field of immunogenetics of psoriasis leads to personalized medicine.

Bedside to bench: defining the immunopathogenesis of psoriatic arthritis

Psoriatic arthritis (PsA) is an immune-mediated, systemic inflammatory disorder. PsA can present with heterogeneous clinical features. Advances in understanding the immunopathogenesis of PsA have helped to facilitate the development of agents targeting specific components of the dysregulated inflammatory and immune responses relevant to PsA. Interestingly, agents with distinct mechanisms of action have shown differential responses across the various disease domains of PsA, counter to what might have been expected from basic science investigations. Here, we review data utilizing various novel targeted therapies for PsA, focusing on biologic and targeted synthetic therapies. These data might support the idea of a 'bedside to bench' concept, whereby results from clinical trials of specific targeted therapies inform our understanding of the immunopathogenesis of PsA. For example, TNF inhibition confers substantial and comparable benefit for all domains of PsA, supporting the view that TNF is a central pro-inflammatory cytokine across diverse areas of disease involvement. On the other hand, inhibition of IL-12-IL-23, as compared with inhibition of TNF, has greater efficacy for psoriasis, comparable efficacy for peripheral arthritis, but was ineffective in studies of axial spondyloarthritis. Data from studies of agents with distinct mechanisms of action will help to further refine our understanding of the immunopathogenesis of PsA.

Autoimmune pathways in mice and humans are blocked by pharmacological stabilization of the TYK2 pseudokinase domain

TYK2 is a nonreceptor tyrosine kinase involved in adaptive and innate immune responses. A deactivating coding variant has previously been shown to prevent receptor-stimulated activation of this kinase and provides high protection from several common autoimmune diseases but without immunodeficiency. An agent that recapitulates the phenotype of this deactivating coding variant may therefore represent an important advancement in the treatment of autoimmunity. BMS-986165 is a potent oral agent that similarly blocks receptor-stimulated activation of TYK2 allosterically and with high selectivity and potency afforded through optimized binding to a regulatory domain of the protein. Signaling and functional responses in human TH17, TH1, B cells, and myeloid cells integral to autoimmunity were blocked by BMS-986165, both in vitro and in vivo in a phase 1 clinical trial. BMS-986165 demonstrated robust efficacy, consistent with blockade of multiple autoimmune pathways, in murine models of lupus nephritis and inflammatory bowel disease, supporting its therapeutic potential for multiple immune-mediated diseases.

Guselkumab for the treatment of psoriasis - evidence to date

Psoriasis is a chronic, immune-mediated, inflammatory, and debilitating skin disease with significant impact on patients’ quality of life. Its pathogenesis is complex and not yet fully understood. However, the IL-23/IL-17 axis is currently considered the main pathogenic pathway in psoriasis. Guselkumab is a fully human immunoglobulin G1 λ (IgG1λ) monoclonal antibody (mAb) that binds to the p19 subunit of IL-23. It is the first of its class, already approved by the US Food and Drug Administration (FDA), as well as the European Medicines Agency (EMA) for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for either systemic therapy or phototherapy. Several clinical trials have demonstrated potential benefits of guselkumab over other already approved immunomodulators in terms of safety and efficacy. The results of the head-to-head trial ECLIPSE were recently released and are addressed in this review. They contribute to the increasing confidence in guselkumab, demonstrating great potential for long-term treatment of psoriasis. However, further long-term data and additional comparative studies will be essential for positioning guselkumab in the therapeutic armamentarium for psoriasis.

What's New in Psoriasis

Psoriasis is a common, chronic inflammatory skin disease that is characterized by the formation of sharply demarcated, scaly, erythematous plaques. It affects about 2.2% of the population in the United States and has a large impact on patient quality of life. Many advances have been made in the last few years in the management of psoriasis. Proinflammatory cytokines play major roles in the pathogenesis of disease. Biologic medications targeting the aforementioned cytokines have been developed and studied for the management of psoriatic disease. This article summarizes the newest findings in the management of psoriasis and the various treatment options available.

Guselkumab for the treatment of adults with moderate to severe plaque psoriasis

INTRODUCTION

Guselkumab is a subcutaneously administered monoclonal antibody that targets the IL-23p19 cytokine subunit and has been approved by the US FDA and the EMA for the treatment of moderate-to-severe psoriasis in adult patients. Areas covered: This review outlines the pharmacologic properties, efficacy and safety of guselkumab for the treatment of moderate-to-severe plaque psoriasis in adults. Expert opinion: In clinical trials, guselkumab markedly improved disease, regardless of topographical locations and patient subpopulations, with corresponding improvements in quality of life measures, and was generally well tolerated. Guselkumab has been shown to be more effective than adalimumab in phase III pivotal trials (VOYAGE 1 and VOYAGE 2) at both week 16 and week 24 for PASI75, PASI90, PASI100 and IGA(0/1); the corresponding PASI 90 response rates at week 16 were 73.3% vs 49.7% in VOYAGE 1 and 70.0% vs 46.8% in VOYAGE 2 (P < 0.001 in both). Guselkumab has been shown to be superior to secukinumab in PASI90 response rate at week 48 in a head-to-head trial (ECLIPSE); it is also successful in treating patients with incomplete responses to adalimumab (VOYAGE 2) and ustekinumab (NAVIGATE). Guselkumab may be effective in treating psoriatic arthritis, with several phase III trials ongoing.

Efficacy and Safety of Brodalumab in Patients with Moderate-to-Severe Plaque Psoriasis and Skin of Color: Results from the Pooled AMAGINE-2/-3 Randomized Trials

BACKGROUND

Data on treatment outcomes in patients with psoriasis who have skin of color are limited. Brodalumab has shown efficacy in patients with moderate-to-severe plaque psoriasis.

OBJECTIVE

Our objective was to evaluate the efficacy, safety, and health-related quality of life associated with brodalumab in patients with skin of color participating in two phase III, multicenter, randomized, double-blind, placebo- and active comparator-controlled studies (AMAGINE-2/-3).

METHODS

Patients were self-categorized into racial subgroups (black, Asian, or white) or the non-mutually exclusive ethnic subgroup Hispanic/Latino. Patients were randomized to receive brodalumab 210 mg every 2 weeks (Q2W) or ustekinumab (45 mg in patients weighing ≤ 100 kg and 90 mg in patients weighing > 100 kg) for 52 weeks. Skin clearance was monitored using the Psoriasis Area and Severity Index (PASI) and Static Physician's Global Assessment (sPGA). Treatment-emergent adverse events (TEAEs) were summarized by treatment and racial and ethnic subgroup. Health-related quality of life was assessed using the Dermatology Life Quality Index (DLQI).

RESULTS

During the 12-week induction phase, 613 patients received ustekinumab (black, n = 20; Asian, n = 24; white, n = 551; Hispanic/Latino, n = 68) and 1236 patients received brodalumab 210 mg Q2W (black, n = 36; Asian, n = 39; white, n = 1116; Hispanic/Latino, n = 132). At week 52, a total of 590 patients received continuous ustekinumab (black, n = 19; Asian, n = 23; white, n = 532; Hispanic/Latino, n = 64) and 339 patients were re-randomized to continue receiving brodalumab 210 mg Q2W (black, n = 10; Asian, n = 7; white, n = 308; Hispanic/Latino, n = 40). Among patients who received brodalumab 210 mg Q2W, skin clearance response rates were similar across racial and ethnic subgroups at week 12 and week 52; rates of 75%, 90%, and 100% improvement in PASI from baseline were also higher, as was sPGA score ≤ 1, than in patients who received ustekinumab across all racial and ethnic subgroups. Rates of TEAEs and ≥ 5-point improvement in DLQI score were similar across racial and ethnic subgroups.

CONCLUSIONS

Brodalumab 210 mg Q2W is well tolerated and efficacious across diverse racial and ethnic subgroups in patients with psoriasis, including black, Asian, white, and Hispanic/Latino patients.

TRIAL REGISTRY

ClinicalTrials.gov identifier NCT01708603 (AMAGINE-2); NCT01708629 (AMAGINE-3).

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.

Targeting p19 as a treatment option for psoriasis: an evidence-based review of guselkumab

Further understanding of psoriasis pathogenesis has led to the development of effective biologic medications. Guselkumab (GUS) is a subcutaneously administered monoclonal antibody that targets the p19 cytokine subunit in IL-23 and IL-39 and is US Food and Drug Administration (FDA) approved for the treatment of moderate-to-severe psoriasis in adult patients. This review evaluates the pharmacology, safety and efficacy of GUS in patients with psoriasis. We performed a literature review by searching online databases including PubMed and Google Scholar. In clinical trials, GUS improved diseases including psoriatic arthritis (PsA) and specific areas of disease (scalp, feet, hands and fingernails). In the Phase III trials VOYAGE 1 and 2, more GUS than adalimumab (ADM) patients experienced a ≥90% reduction in Psoriasis Area and Severity Index (PASI) score (PASI90) (VOYAGE 1: 80.2% vs 53.0%; VOYAGE 2: 75.2% vs 54.8%; P<0.001 for both) and Investigator Global Assessment score of 0 or 1 (VOYAGE 1: 84.2% vs 61.7%; VOAYGE 2: 83.5% vs 64.9%; P<0.001 for both) at Week 24. GUS was also successful in treating patients unresponsive to ADM and ustekinumab in the VOYAGE 2 and NAVIGATE trials, respectively. While long-term data are necessary, GUS appears to have a favorable side effect profile with most common adverse effects including nasopharyngitis and upper respiratory tract infections. GUS is a well-tolerated and effective medication for patients with psoriasis. Continued study of GUS and the p19 subunit will help to determine GUS's ultimate place in therapy.

Psoriasis in Skin of Color: Insights into the Epidemiology, Clinical Presentation, Genetics, Quality-of-Life Impact, and Treatment of Psoriasis in Non-White Racial/Ethnic Groups

Psoriasis is a chronic inflammatory skin condition affecting diverse racial/ethnic groups throughout the world. Large population-based studies suggest that psoriasis occurs most often in individuals of European ancestry, followed by black and Hispanic individuals, although the true prevalence of psoriasis in non-white individuals is likely underestimated. Despite similarities in psoriasis between ethnic groups, there are notable differences in the presentation, quality-of-life impact, and treatment of psoriasis with important implications for the management of non-white individuals. Overall, heterogeneity in psoriasis susceptibility alleles, in combination with cultural and socioeconomic factors, may explain these differences. In this article, we review the epidemiology, clinical presentation, genetic polymorphisms, quality-of-life impact, and treatment nuances of psoriasis in patients with skin of color.