Role of IL-17 in plaque psoriasis: therapeutic potential of ixekizumab

Notch signaling regulates Th17 cells differentiation through PI3K/AKT/mTORC1 pathway and involves in the thyroid injury of autoimmune thyroiditis

PURPOSE

Autoimmune Thyroiditis (AIT) is the most common thyroid disease; however, there were no measures to prevent the progression of the disease. The present study attempts to identify that Notch signaling regulates the differentiation of T helper 17 (Th17) cells by activating downstream Phosphatidylinositol-3 kinase/protein kinase/mechanistic target of rapamycin complex 1 (PI3K/AKT/mTORC1) pathway participating in the thyroid injury of the experimental autoimmune thyroiditis (EAT).

METHODS

In vivo experiments, mice were randomly divided into 4 groups: a control group, an EAT group, and two groups with LY294002 treatment (pTg plus 25 mg/kg or 50 mg/kg LY294002, respectively). The degrees of thyroiditis were evaluated, and the percentage of Th17 cells, expression of interleukin-17A (IL-17A), and the main components of the Notch-PI3K signaling pathway were detected in different groups. In vitro experiments, two different dosages of LY294002 (25 and 50 μM) were used to intervene splenic mononuclear cells (SMCs) from EAT mice to further evaluate the regulatory effect of Notch-PI3K pathway on Th17 cells.

RESULTS

Our data demonstrate that the infiltration of Th17 cells and the expressions of IL-17A, Notch, hairy and split 1 (Hes1), p‑AKT (Ser473), p‑AKT (Thr308), p‑mTOR (Ser2448), S6K1, and S6K2 increased remarkably in EAT mice. After PI3K pathway was blocked, the degrees of thyroiditis were significantly alleviated, and the proportion of Th17 cells, the expression of IL-17A, and the above Notch-PI3K pathway-related molecules decreased in a dose-dependent manner. Additionally, the proportion of Th17 cells was positively correlated with the concentration of serum thyroglobulin antibody (TgAb), IL-17A, and Notch-PI3K pathway-related molecules mRNA levels.

CONCLUSIONS

Notch signal promotes the secretion of IL-17A from Th17 cells by regulating the downstream PI3K/AKT/mTORC1 pathway through Hes-Phosphatase and tensin homolog (PTEN) and participates in thyroid autoimmune damage, and the PI3K pathway inhibitor may play important effects on AIT by affecting Th17 cells differentiation.

Distributive Shock in Erythrodermic Psoriasis Treated With Norepinephrine and Vasopressin: A Case Report

Distributive shock and hypothermia are two unusual and potentially fatal complications of erythroderma, a rare complication of psoriasis. Very few cases of erythrodermic psoriasis have been reported, particularly in the United States, which may pose a diagnostic challenge for internists. We present a case report of distributive hemodynamic instability and hypothermia in a 61-year-old female who initially presented with acute altered mental status thought to be related to an infectious etiology.

On and off-label uses of interleukin-17 inhibitors for patients with plaque-type psoriasis in Thailand: a real-world study

BACKGROUND

Off-label uses of biologics in the treatment of psoriasis are usually implemented in limited-resource settings and studies regarding their response profiles are limited.

METHOD

This was a retrospective study performed in moderate-to-severe plaque-type psoriasis patients who had been treated with either secukinumab, ixekizumab or brodalumab at a university hospital in Thailand between 1 January 2017 and 1 April 2021.

RESULTS

A total of 142 patients were included in the data analysis consisting of three groups of 48 patients, 86 patients, and 8 patients treated by secukinumab, ixekizumab, and brodalumab, respectively. Patients were then classified into five groups according to the dosing pattern they received; on-label, off-label with induction, off-label with specific pattern, off-label with irregular dosing interval <8 weeks and >8 weeks. Considering both secukinumab and ixekizumab, the adjusted hazard ratios (95%CI) for complete skin clearance of the four off-label regimens were 2.2(0.9-5.2), 1.9 (0.9-3.9), 1.0 (0.4-2.2), and 1.6 (0.7-3.6), compared to on-label regimen, respectively. In each biologic drug, almost all off-label dosing regimens demonstrated higher adjusted hazard ratios compared to on-label regimen.

CONCLUSION

Off-label, patient-oriented regimens could be a promising choice of IL-17 inhibitors for administration in special settings. Off-label regimens are not inferior in terms of skin clearance to an on-label regimen in the efficacy of psoriasis treatment of secukinumab and ixekizumab but do cause more flares. The decision to use off-label regimens must account for the benefits and associated risks.

Comparing the efficacy and safety of IL-17 inhibitors for treatment of moderate-to-severe psoriasis: a randomized double blind pilot study with a review of literature

Introduction

Psoriasis is a chronic skin disease in which interleukin-17A (IL-17A) has been found to play an important role. Commercially available anti-IL-17 drugs include brodalumab, ixekizumab (IXE), and secukinumab (SEC).

Aim

To compare the safety and efficacy of IXE and SEC in patients with moderate-to-severe plaque psoriasis.

Material and methods

The patients were randomized to the IXE or SEC group. Effectiveness was estimated by Physician's Global Assessment (PGA), Psoriasis Area and Severity Index (PASI), and Dermatology Life Quality Index (DLQI). Safety was assessed by documentation of adverse effects (AEs), routine laboratory values, and injection-site and allergic reactions.

Results

There were 155 patients in the IXE group and 158 in the SEC group. At week 12, PASI 75 was 76.77% (IXE) vs. 67.09% (SEC); PASI 90 42.58% (IXE) vs. 32.28% (SEC); PGA score of 0 or 1 at week 40 (79.52% vs. 74.4%) and at week 52 (61.83% vs. 58.12%) (p < 0.001). Also, DLQI score improvement was more pronounced in the IXE group. The rates and types of AEs were similar in both groups.

Conclusions

Although both groups demonstrated a robust clinical response, a significant improvement in patient quality of life, and a satisfactory safety profile, the IXE group scored a notch higher.

Drug survival of ixekizumab, TNF inhibitors, and other IL-17 inhibitors in real-world patients with psoriasis: The Corrona Psoriasis Registry

To compare drug survival of ixekizumab to other IL‐17 inhibitors (IL‐17i) and TNF inhibitors (TNFi) among patients with psoriasis (PsO) in a real‐world setting. Participants included adult PsO patients enrolled in the Corrona Psoriasis Registry who initiated ixekizumab, TNFi, or other IL‐17i between 16 March 2016 to 10 August 2019 and completed ≥1 follow‐up visit. Multivariable adjusted hazard ratios (HR) were calculated to estimate the risk for drug discontinuation in the ixekizumab group relative to the other drugs. Among the 1604 drug initiations, 552 initiated ixekizumab, 450 initiated TNFi, and 602 initiated other IL‐17i. Mean age was 51 years, 49% were women, and 52% were obese (BMI > 30). Ixekizumab patients had a higher proportion of patients with PASI >12 at drug initiation (24%) than TNFi (15%) and other IL‐17i (19%). Over a median of 11 months of follow‐up, 723/1604 (45%) drug discontinuations occurred. Persistence of ixekizumab, TNFi, and other IL‐17i at 24‐months were 68%, 33%, and 46%, among biologic‐naïve patients (n = 543), and 46%, 23%, and 36%, for biologic‐experienced patients (n = 1061), respectively. Ixekizumab patients had a 64% lower risk of discontinuation vs TNFi (HR = 0.36; 95% CI 0.27‐0.47) and a 31% lower risk vs other IL‐17i (HR = 0.69, 95% CI 0.55‐0.87) after adjustment for biologic experience and other covariates. HRs were similar when limited to patients with moderate‐to‐severe PsO (BSA > 3, PASI > 3, and IGA > 1, n = 1076) at initiation. In our study of real‐world patients with PsO, initiators of ixekizumab had more prolonged drug survival than both initiators of TNFi and other IL‐17i up to 2 years of follow‐up.

Understanding characteristics of patients newly initiating ixekizumab: findings from the Corrona Psoriasis Registry

Background: Real-world data on patients newly initiating ixekizumab is limited. Our study describes the characteristics of patients who initiated ixekizumab and other biologics for psoriasis treatment in North American dermatological practices. Materials & methods: Characteristics of patients ascertained at registry enrollment are described via means and frequencies. Results: Compared with other biologic initiators, ixekizumab initiators had: longer disease duration (17.1 vs 15.1 years); more were considered least severe by body surface area (33 vs 26%); moderate-to-severe by IGA (56 vs 48%); were biologic-experienced (80 vs 52%); obese (54 vs 47%); and experienced greater impact in work productivity (5.3 vs 2.9%) versus other biologic initiators. Conclusion: Psoriasis patients initiating ixekizumab had more severe disease, biologic experience, and worse patient-reported outcomes than those initiating other biologics.

Disease response and patient-reported outcomes among initiators of ixekizumab

OBJECTIVES

There is limited real-world evidence on using ixekizumab in psoriasis patients. Therefore, we characterized patients with psoriasis initiating ixekizumab and report 6-month changes in disease and patient-reported outcomes.

METHODS

Adult patients with psoriasis who initiated ixekizumab and completed a 6-month follow-up visit were enrolled from the Corrona Psoriasis Registry. Disease characteristics and outcomes were assessed at ixekizumab initiation. Outcomes included the mean 6-month change in Psoriasis Area and Severity Index (PASI), body surface area (BSA), Investigator Global Assessment (IGA), and IGA*BSA.

RESULTS

From baseline to follow-up in all patients (n = 136), means decreased for IGA*BSA (-45.5) and BSA (-12.4), and a higher % achieved an absolute PASI ≤ 5 (84.6%), BSA 0-3 (72.1%), and IGA 0/1 (50.7%). Within stratified groups, means decreased for PASI <12 for IGA*BSA (-21.1) and BSA (-6.3); PASI≥12 for IGA*BSA (-94.8) and BSA (-24.6); weight <100 kg for IGA*BSA (-45.1) and BSA (-12.4); weight ≥100 kg for IGA*BSA (-46.2) and BSA (-12.3); concomitant PsA for IGA*BSA (-56.0) and BSA (-15.3); and in no concomitant PsA for IGA*BSA (-36.9) and BSA (-10.0).

CONCLUSIONS

We provide real-world evidence on the benefits of ixekizumab for treating psoriasis, regardless of baseline disease severity, weight, or concomitant PsA.

Autoimmunity to heterogeneous nuclear ribonucleoprotein A1 in psoriatic patients and correlation with disease severity

BACKGROUND AND OBJECTIVES

The heterogeneous nuclear ribonucleoprotein A1 (hnRNP-A1) has been postulated as an autoantigen of psoriasis, but correlation between serum levels of anti-hnRNP-A1 autoantibodies and the severity of disease has not been investigated. We aimed to assess the frequency of anti-hnRNP-A1 autoimmunity in patients with moderate to severe psoriasis and in healthy controls, and to determine the correlation between serum levels of anti-hnRNP-A1 autoantibodies and disease severity.

PATIENTS AND METHODS

We performed a case-control study on 40 adult psoriatic patients with a PASI (Psoriasis Area and Severity Index) of > 10 and 40 healthy controls matched for age and gender. Immunoblotting was used to assess serum levels of anti-hnRNP-A1 autoantibodies.

RESULTS

Anti-hnRNP-A1 autoantibodies were found in 9/40 psoriatic patients (22.5 %) but in no healthy controls. The PASI was significantly higher in anti-hnRNP-A1-positive patients than in anti-hnRNP-A1-negative patients (40.33 ± 3.24 vs 26.06 ± 9.28, p = 0.0001). In patients positive for anti-hnRNP-A1, serum levels of such autoanti-bodies were correlated with the PASI (R = 0.89, p = 0.001).

CONCLUSIONS

Consistent with reports in the literature, our results suggest a role of anti-hnRNP-A1 autoimmunity in psoriasis, although probably not as the primary cause or initial/fundamental event. Unlike previously published reports, our results also suggest that anti-hnRNP-A1 autoimmunity is particularly frequent among psoriatic patients with more severe disease. Further studies are necessary with a larger number of patients.

Th1, Th17, and Treg Responses are Differently Modulated by TNF-α Inhibitors and Methotrexate in Psoriasis Patients

Psoriasis is a chronic, recurrent, immune-mediated, hyperproliferative inflammatory skin disease. The role of the adaptive immune system, particularly of Th1 and Th17 lymphocytes, has been regarded as prominent in the immunopathogenesis of psoriasis, as well as decreased Tregs function. Immunobiological drugs were administered in therapeutic pulses and a few studies evaluate their effects on the immune repertoire. The aim of this study was to evaluate the adaptive immune profile of patients with severe psoriasis under immunobiological treatment in two time points. Thirty-two psoriasis patients and 10 control patients were evaluated. In the group of psoriasis patients, 10 patients were on anti-TNF and 14 patients on methotrexate treatment, while 8 individuals were not treated. IL-17, IFN-γ, TNF-α, IL-6, IL-2, and IL-10 were analyzed. CD4 T cell intracellular cytokines were analyzed. It was observed that stimulation could significantly increase the production of IL-17, IFN-γ, TNF-α, and IL-10 only before anti-TNF pulse therapy. The activation of Th1 and Treg cells after stimulation was significantly higher before anti-TNF pulse. Patients on methotrexate or anti-TNF therapy produced significantly lower levels of TNF-α, IL-10, and IL-6. Furthermore, these patients showed a significant decrease in the activated CD4+ T cells. The treatment with immunomodulator or methotrexate modulates the activation of CD4+ T cells, and anti-TNF treatment appears to have a modulating effect on the activation and production of Th1, Th17, and Treg cells.

IL-17 and limits of success

Interleukin-17 (IL-17) is a potent proinflammatory cytokine that protects a host against fungal and extracellular bacterial infections. On the other hand, excessive or dysregulated production of IL-17 underlines susceptibility to autoimmune disease. Consequently, blocking IL-17 has become an effective strategy for modulating several autoimmune diseases, including multiple sclerosis (MS), psoriasis, and rheumatoid arthritis (RA). Notably, however, IL-17 blockade remains ineffective or even pathogenic against important autoimmune diseases such as inflammatory bowel disease (IBD). Furthermore, the efficacy of IL-17 blockade against other autoimmune diseases, including type 1 diabetes (T1D) is currently unknown and waiting results of ongoing clinical trials. Coming years will determine whether the efficacy of IL-17 blockade is limited to certain autoimmune diseases or can be expanded to other autoimmune diseases. These efforts include new clinical trials aimed at testing second-generation agents with the goal of increasing the efficiency, spectrum, and ameliorating side effects of IL-17 blockade. Here we briefly review the roles of IL-17 in the pathogenesis of selected autoimmune diseases and provide updates on ongoing and recently completed trials of IL-17 based immunotherapies.

Delivering Precision Medicine and Patient-Centred Care Through a Multidisciplinary Approach

The current treatment strategy for patients with inflammatory bowel disease (IBD) aims to enable physicians to deliver optimal care and to improve the role that patients play in treatment decisions. The multidisciplinary team (MDT) approach integrates the patient’s perspective and sees the discussion of treatment options with both gastroenterologists and surgeons as early as possible. The MDT approach is also vital in managing the risk of IBD and cardiovascular-related comorbidities in patients with psoriasis (PsO) and psoriatic arthritis (PsA), where selection of appropriate medication may affect both the rheumatic condition and the associated comorbidity. Close interdisciplinary interactions between gastroenterologists, rheumatologists, and/or dermatologists are vital, and the ensuing knowledge transfer facilitates the provision of optimal patient care. Personalised medicine will have a profound impact on future treatment algorithms in IBD and other chronic inflammatory conditions. Owing to the complexity of these diseases, a novel approach is urgently needed that will aggregate data from multiple systems and integrate it into a so-called ‘IBD interactome’. This may help identify and target the key molecular components responsible for inflammation. Future treatment practices will also address the psychosocial aspects of IBD by empowering patients and integrating their perspective into the shared treatment decision-making process early on.

Biological therapies in psoriasis - revisited

Psoriasis is a chronic, immune mediated disorder affecting approximately 2% of the population. Even in our days, patients with psoriasis are confronted with stigmatization and social rejection. As a result, their quality of life is significantly impaired. Biological therapies have revolutionized the treatment of moderate to severe psoriasis. The aim of this paper is to look over the most important biological therapies available for the management of plaque-type psoriasis.

Novel Biologic Agents Targeting Interleukin-23 and Interleukin-17 for Moderate-to-Severe Psoriasis

Psoriasis is a common, chronic inflammatory skin disease and cannot be cured. The treatment of moderate-to-severe plaque psoriasis has been revolutionized with the development of biologic agents for nearly 20 years. Current studies show that interleukin-23 and interleukin-17 play remarkable roles in the pathogenesis of psoriasis. Interleukin-23 can sustain the differentiation and maintenance of T helper-17 lineage. Interleukin-17 can recruit and stimulate many cells, which play important parts in psoriasis through interacting with the interleukin-17 receptor. Several biologic agents targeting interleukin-23, interleukin-17, or their receptors are now in different stages: some are approved or clinical trials are in progress. Ustekinumab targets interleukin-23/interleukin-12p40; risankizumab, guselkumab, and tildrakizumab target interleukin-23p19; secukinumab and ixekizumab target interleukin-17A; and brodalumab targets the interleukin-17 receptors. All of these agents have good efficacy in treating moderate-to-severe psoriasis.

Cutaneous Manifestations of Reactions to Biologics

PURPOSE OF REVIEW

The goal of this paper is to review the major adverse cutaneous reactions that have been reported to the most commonly used biologics.

RECENT FINDINGS

Anti-TNF agents and immune checkpoint inhibitors have significant, immune-mediated cutaneous manifestations that can necessitate discontinuation. Anti-TNF agents, IL-6 inhibitors, and IL-12/23 inhibitors can paradoxically cause psoriasis flares or unmask previously undiagnosed psoriasis. IL-17 inhibitors are unique in increasing risk for Candida infections. Benign injection site reactions, non-specific rash, cellulitis, and hypersensitivity reactions are relatively common adverse events. A wide variety of cutaneous reactions caused by biologics have been reported, ranging from benign injection site reactions to life-threatening cutaneous reactions necessitating discontinuation of the implicated biologic agent.

Autoimmune thyroid diseases and Th17/Treg lymphocytes

Years of researches have demonstrated that the imbalance of Th17 and Tregs contribute to the thyroid autoimmunity and the severity of autoimmune thyroid disease (AITD). The underlying mechanism comprises inherent genetic predisposition, abnormality of Th17 and Treg related biological molecules, and gut microbiota disorder. New therapeutic strategies have been developed to improve the Th17/Treg equilibrium, including regulation of intracellular signaling pathways, neutralization of Th17-related cytokines, as well as manipulation of Th17 and Treg specific transcription factors. Although a few of these agents are applied into AITD, the clinic prospect is promising.