Efficacy and safety of etanercept in psoriasis/psoriatic arthritis: an updated review

Therapeutic Development Based on the Immunopathogenic Mechanisms of Psoriasis

Psoriasis, a complex inflammatory autoimmune skin disorder that affects 2–3% of the global population, is thought to be genetically predetermined and induced by environmental and immunological factors. In the past decades, basic and clinical studies have significantly expanded knowledge on the molecular, cellular, and immunological mechanisms underlying the pathogenesis of psoriasis. Based on these pathogenic mechanisms, the current disease model emphasizes the role of aberrant Th1 and Th17 responses. Th1 and Th17 immune responses are regulated by a complex network of different cytokines, including TNF-α, IL-17, and IL-23; signal transduction pathways downstream to the cytokine receptors; and various activated transcription factors, including NF-κB, interferon regulatory factors (IRFs), and signal transducer and activator of transcriptions (STATs). The biologics developed to specifically target the cytokines have achieved a better efficacy and safety for the systemic management of psoriasis compared with traditional treatments. Nevertheless, the current therapeutics can only alleviate the symptoms; there is still no cure for psoriasis. Therefore, the development of more effective, safe, and affordable therapeutics for psoriasis is important. In this review, we discussed the current trend of therapeutic development for psoriasis based on the recent discoveries in the immune modulation of the inflammatory response in psoriasis.

Safety update of etanercept treatment for moderate to severe plaque psoriasis

Introduction: Conventional topical therapies and disease-modifying anti-rheumatic drugs (DMARDs) for patients with psoriasis are often linked to inadequate outcomes and risk of multiple adverse effects. Biologic agents such as etanercept (ETN) have revolutionized the therapeutic management of psoriasis, allowing the treatment of most difficult cases, and fragile patients.Areas covered: The authors searched PubMed using the term 'psoriasis,' 'etanercept,' and 'safety.' Articles considered by the authors to be most relevant, such as randomized controlled studies, cohort studies, and review articles placing emphasis on studies of efficacy and safety were selected. Case reports and letters relating to safety were also included. The main sources of data referenced by these articles were also included in the review. Besides, to get the relevant studies, the reference lists were examined to identify the potentially available studies. The aim of this review is to describe the safety profile of ETN, used for psoriasis treatment, focusing on related clinical implications.Expert opinion: ETN has a favorable safety profile, and its use should be largely considered in psoriatic patients. Caution should be recommended in case of chronic heart failure, autoimmune disease, previous malignancies, familial history of demyelinating diseases, latent TBC infection, chronic HBV and HCV infection or HIV.

Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people: systematic review and economic evaluation

BACKGROUND

Psoriasis is a chronic inflammatory disease that predominantly affects the skin. Adalimumab (HUMIRA^®, AbbVie, Maidenhead, UK), etanercept (Enbrel^®, Pfizer, New York, NY, USA) and ustekinumab (STELARA^®, Janssen Biotech, Inc., Titusville, NJ, USA) are the three biological treatments currently licensed for psoriasis in children.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of adalimumab, etanercept and ustekinumab within their respective licensed indications for the treatment of plaque psoriasis in children and young people.

DATA SOURCES

Searches of the literature and regulatory sources, contact with European psoriasis registries, company submissions and clinical study reports from manufacturers, and previous National Institute for Health and Care Excellence (NICE) technology appraisal documentation.

REVIEW METHODS

Included studies were summarised and subjected to detailed critical appraisal. A network meta-analysis incorporating adult data was developed to connect the effectiveness data in children and young people and populate a de novo decision-analytic model. The model estimated the cost-effectiveness of adalimumab, etanercept and ustekinumab compared with each other and with either methotrexate or best supportive care (BSC), depending on the position of the intervention in the management pathway.

RESULTS

Of the 2386 non-duplicate records identified, nine studies (one randomised controlled trial for each drug plus six observational studies) were included in the review of clinical effectiveness and safety. Etanercept and ustekinumab resulted in significantly greater improvements in psoriasis symptoms than placebo at 12 weeks' follow-up. The magnitude and persistence of the effects beyond 12 weeks is less certain. Adalimumab resulted in significantly greater improvements in psoriasis symptoms than methotrexate for some but not all measures at 16 weeks. Quality-of-life benefits were inconsistent across different measures. There was limited evidence of excess short-term adverse events; however, the possibility of rare events cannot be excluded. The majority of the incremental cost-effectiveness ratios for the use of biologics in children and young people exceeded NICE's usual threshold for cost-effectiveness and were reduced significantly only when combined assumptions that align with those made in the management of psoriasis in adults were adopted.

LIMITATIONS

The clinical evidence base for short- and long-term outcomes was limited in terms of total participant numbers, length of follow-up and the absence of young children.

CONCLUSIONS

The paucity of clinical and economic evidence to inform the cost-effectiveness of biological treatments in children and young people imposed a number of strong assumptions and uncertainties. Health-related quality-of-life (HRQoL) gains associated with treatment and the number of hospitalisations in children and young people are areas of considerable uncertainty. The findings suggest that biological treatments may not be cost-effective for the management of psoriasis in children and young people at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year, unless a number of strong assumptions about HRQoL and the costs of BSC are combined. Registry data on biological treatments would help determine safety, patterns of treatment switching, impact on comorbidities and long-term withdrawal rates. Further research is also needed into the resource use and costs associated with BSC. Adequately powered randomised controlled trials (including comparisons against placebo) could substantially reduce the uncertainty surrounding the effectiveness of biological treatments in biologic-experienced populations of children and young people, particularly in younger children. Such trials should establish the impact of biological therapies on HRQoL in this population, ideally by collecting direct estimates of EuroQol-5 Dimensions for Youth (EQ-5D-Y) utilities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016039494.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Can etanercept treatment failure in moderate-to-severe psoriasis be overcome by addition of low-dose methotrexate? A single-center experience

BACKGROUND

Loss of efficacy is a major anticipated shortcoming of utilizing etanercept and other biologic agents for treating moderate-to-severe psoriasis.

PURPOSE

To investigate the addition of low-dose methotrexate as a means to increase etanercept drug survival.

METHODS

Eleven patients with severe psoriasis were switched to a combination of etanercept with low-dose methotrexate therapy, after a primary or secondary failure with etanercept treatment as a monotherapy. Time period for cessation of combined treatment and side effects were documented. The effect of previous methotrexate treatment was investigated.

RESULTS

Six men and five women were included in the study. The patients had moderate-to-severe psoriasis with a mean baseline Psoriasis Area and Severity Index (PASI) of 29 (median 25). Median duration of etanercept monotherapy was 12 months. Median duration of combined treatment was 13 months. Combined treatment was discontinued in three patients due to side effects. Previous failure of methotrexate monotherapy did not alter the duration of the combined treatment.

CONCLUSION

Addition of low-dose methotrexate may rescue etanercept therapy after failure of etanercept monotherapy in patients with moderate-to-severe psoriasis.

Natural Modulators of Endosomal Toll-Like Receptor-Mediated Psoriatic Skin Inflammation

Psoriasis is a chronic inflammatory autoimmune disease that can be initiated by excessive activation of endosomal toll-like receptors (TLRs), particularly TLR7, TLR8, and TLR9. Therefore, inhibitors of endosomal TLR activation are being investigated for their ability to treat this disease. The currently approved biological drugs adalimumab, etanercept, infliximab, ustekinumab, ixekizumab, and secukizumab are antibodies against effector cytokines that participate in the initiation and development of psoriasis. Several immune modulatory oligonucleotides and small molecular weight compounds, including IMO-3100, IMO-8400, and CPG-52364, that block the interaction between endosomal TLRs and their ligands are under clinical investigation for their effectiveness in the treatment of psoriasis. In addition, several chemical compounds, including AS-2444697, PF-05387252, PF-05388169, PF-06650833, ML120B, and PHA-408, can inhibit TLR signaling. Although these compounds have demonstrated anti-inflammatory activity in animal models, their therapeutic potential for the treatment of psoriasis has not yet been tested. Recent studies demonstrated that natural compounds derived from plants, fungi, and bacteria, including mustard seed, Antrodia cinnamomea extract, curcumin, resveratrol, thiostrepton, azithromycin, and andrographolide, inhibited psoriasis-like inflammation induced by the TLR7 agonist imiquimod in animal models. These natural modulators employ different mechanisms to inhibit endosomal TLR activation and are administered via different routes. Therefore, they represent candidate psoriasis drugs and might lead to the development of new treatment options.

Ten years on: the impact of biologics on the practice of dermatology

This review delivers a commentary on the first decade of biologics' use in psoriasis and provides a glimpse of the pipeline of therapies currently in development for psoriasis that will enhance the therapeutic armamentarium available to the dermatologist. In addition, the authors revisit the rationale for the development of biological therapies, inventory the available therapies of today, and retrospectively assess their impact on the dermatology practice as it relates to the management of patients with psoriasis.

Baseline anti-dsDNA concentrations and previous treatments predict response to Adalimumab and Etanercept: a retrospective investigation of 146 psoriasis patients

BACKGROUND

Adalimumab and Etanercept are TNF-α antagonists commonly used for treatment of moderate-to-severe psoriasis and psoriatic-arthritis. Reliable instruments to assist the selection of patients for a specific treatment in a real-world scenario are unavailable.

OBJECTIVE

To identify patient characteristics and baseline laboratory parameters predicting response to Adalimumab- and Etanercept-treatment.

METHODS

We report a retrospective observational study including 116 and 64 psoriasis-patients treated with Adalimumab and Etanercept, respectively, at a dermatological outpatient clinic of a university hospital. Thirty four patients contributed data to both biologics. First occurrence of either loss-of-response or serious-side-effects (LOR/SSE) was chosen as clinical endpoint and predictors were identified using Cox-regression.

RESULTS

Baseline anti-double-stranded DNA (anti-dsDNA) concentrations, number of previous treatments with TNF-α antagonists in general and previous treatment with Etanercept in particular significantly predicted LOR/SSE to Adalimumab. The predictive effect of baseline anti-dsDNA was conserved in TNF-α antagonist naïve patients. Number of previous systemic treatments other than TNF-α antagonists significantly predicted LOR/SSE to Etanercept. Age and baseline psoriasis area and severity index (PASI) did not predict response to either biologic in a clinically significant manner.

CONCLUSION

Our data suggests that treatment with Adalimumab may promise best results in psoriasis-patients with (A) low baseline anti-dsDNA concentrations, and (B) no previous TNF-α antagonist treatment. A clinically significant predictive effect of age and baseline PASI on response to Adalimumab and Etanercept is unlikely.

Paradoxical Reaction to Golimumab: Tumor Necrosis Factor α Inhibitor Inducing Psoriasis Pustulosa

Importance

Golimumab is a human monoclonal antibody, used for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Adverse reactions are increasing with this class of medication (tumor necrosis factor α inhibitors).

Observations

The authors present a case of a female patient who presented with psoriasis pustulosa after the use of golimumab for rheumatoid arthritis.

Conclusions and Relevance

Paradoxically, in this case, golimumab, which is used for psoriasis, induced the pustular form of this disease. We are observing an increasing number of patients who develop collateral effects with tumor necrosis factor α inhibitors, and the understanding of the mechanism of action and how these adverse reactions occur may contribute to avoid these sometimes severe situations.

Sequential use of biologics in the treatment of moderate-to-severe plaque psoriasis

A number of biologic agents, including the tumour necrosis factor (TNF) antagonists etanercept, adalimumab and infliximab, and the interleukin (IL)-12/IL-23 antagonist ustekinumab, are available for the treatment of moderate-to-severe plaque psoriasis in the U.K. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. The efficacy of biologics, the potential mechanisms of primary and secondary failure and the evidence for sequencing therapy among TNF antagonists and between TNF antagonists and IL-12/IL-23 blockade are reviewed. As psoriasis biologics registers begin to produce long-term safety and efficacy data, therapy decisions in plaque psoriasis may become more objective, and it may be possible to individualize treatment based on clinical or pharmacogenetic information.

Anti-tumor necrosis factor (TNF) drugs for the treatment of psoriatic arthritis: an indirect comparison meta-analysis

Objective

To evaluate the comparative effectiveness of available tumor necrosis factor-α inhibitors (anti-TNFs) for the management of psoriatic arthritis (PsA) in patients with an inadequate response to disease-modifying antirheumatic drugs (DMARDs).

Methods

We used an exhaustive search strategy covering randomized clinical trials, systematic reviews and health technology assessments (HTA) published on anti-TNFs for PsA. We performed indirect comparisons of the available anti-TNFs (adalimumab, etanercept, golimumab, and infliximab) measuring relative risks (RR) for the psoriatic arthritis response criteria (PsARC), mean differences (MDs) for improvements from baseline for the Health Assessment Questionnaire (HAQ) by PsARC responders and non-responders, and MD for the improvements from baseline for the psoriasis area and severity index (PASI). When the reporting of data on intervention group response rates and improvements were incomplete, we used straightforward conversions based on the available data.

Results

We retrieved data from 20 publications representing seven trials, as well as two HTAs. All anti-TNFs were significantly better than control, but the indirect comparison did not reveal any statistically significant difference between the anti-TNFs. For PsARC response, golimumab yielded the highest RR and etanercept the second highest; adalimumab and infliximab both yielded notably smaller RRs. For HAQ improvement, etanercept and infliximab yielded the largest MD among PsARC responders. For PsARC nonresponders, etanercept, infliximab, and golimumab yielded similar MDs, and adalimumab a notably lower MD. For PASI improvement, infliximab yielded the largest MD and golimumab the second largest, while etanercept yielded the smallest MD. In some instances, the estimated magnitudes of effect were notably different from the estimates of previous HTA indirect comparisons.

Conclusion

There is insufficient statistical evidence to demonstrate differences in effectiveness between available anti-TNFs for PsA. Effect estimates seem sensitive to the analytic approach, and this uncertainty should be taken into account in future economic evaluations.

Improved analytical methods for the detection and quantification of neutralizing antibodies to biopharmaceuticals

Biopharmaceuticals are used extensively for the treatment of a number of chronic debilitating and fatal diseases such as cancer and inflammatory or autoimmune diseases. Although biopharmaceuticals are in general well tolerated, the development of anti-drug antibodies can impair their safety and efficacy. Assessment of immunogenicity is essential for a more effective and rational use of biopharmaceuticals, and is dependent upon the establishment of efficient standardized assays that allow direct comparison of immunogenicity data with clinical outcome. Although regulatory authorities recommend the use of cell-based assays that reflect the mechanism of action of the drug for the detection of neutralizing anti-drug antibodies, conventional cell-based assays are difficult to standardize and often give variable results. A number of strategies have been adopted to improve the performance of cell-based assays, including quantification of drug-induced proteins using either real-time RT-PCR or branched DNA to detect mRNA, or ELISAs to detect protein, bridging assays using immobilized cells and the use of reporter gene assays. The relative merits and limitations of each of these methods is reviewed herein.

Comparative assessment of biologics in treatment of psoriasis: drug design and clinical effectiveness of ustekinumab

The development of psoriasis and psoriatic arthritis is a multistep process that leads to chronic or recurrent inflammation. Recent studies have suggested the importance of T helper (TH)1 and TH17 cells, accessory cells, and proinflammatory cytokines in the pathogenesis of the enthesis, synovium, and skin involvement in psoriasis in the presence of susceptibility genes that remain quiescent until triggered. Biologics, such as soluble CTLA-4 immunoglobulin, tumor necrosis factor (TNF) inhibitors, and ustekinumab, inhibit T cell activation which eventually leads to further stimulation of the interleukin 12, 17, and 23 axis, TNF-α, and lymphotoxin-α. Treatment with TNF-α blockers has been effective in refractory psoriasis and psoriatic arthritis, but there is still a subgroup of patients who do not respond to TNF inhibitors and, paradoxically, when treated, may develop TNF-induced psoriasis. Ustekinumab, because of its different mechanism of action at the level of the interleukin 12, 17, and 23 pathways, is an alternative treatment for this group of patients.

Drug persistence, effectiveness and safety assessment of anti-TNF therapies in psoriatic arthritis

INTRODUCTION

Anti-TNF therapies have been introduced for the management of psoriatic arthritis (PsA). There is a need to assess their effectiveness and safety in clinical practice.

AREAS COVERED

This review examines the emerging evidence of effectiveness, safety and drug persistence of anti-TNF therapies in PsA. It also assesses their impact on quality of life and physical functioning in patients with PsA, as well as potential predictors associated with changes in these domains. Several studies from different countries have demonstrated the effectiveness of the anti-TNF therapies in the management of PsA. These therapies have also been shown to be safe and well tolerated over a median usage of 3 years when compared to conventional disease modifying antirheumatic drugs. They also improved quality of life and physical functioning of patients suffering from PsA.

EXPERT OPINION

Anti-TNF therapies are effective and safe in the management of PsA. Improvements in disease activity have been shown to be associated with improvements in quality of life of PsA patients receiving anti-TNF therapies.

Etanercept: an evolving role in psoriasis and psoriatic arthritis

Tumor necrosis factor alpha (TNFalpha) plays a key pathophysiological role in psoriasis and psoriatic arthritis (PsA). Recent interest has thus focused on the clinical potential of TNFalpha antagonists (e.g. etanercept) in these settings. In psoriasis, several large pooled analyses and well-designed clinical trials documented the significant clinical efficacy and generally favorable tolerability of etanercept for up to 96 weeks. Similarly, in PsA, a large phase III trial showed that, etanercept significantly reduced arthritic symptoms and inhibited radiographic disease progression; sustained clinical benefit was again evident for up to 2 years. Etanercept is at the forefront of psoriatic disease management, and continued evolution and evaluation of the compound - for example, in detailed comparative studies and economic analyses - is likely to confirm a key role for etanercept in the treatment of psoriasis and PsA.

Etanercept in a patient with severe psoriasis and latent viral hepatic disease and latent tuberculosis

This case report describes the effective use of etanercept in a 63-year-old male patient with moderate to severe psoriasis and vitiligo unresponsive to local and systemic therapies. Latent tuberculosis was diagnosed at baseline and the patient was treated with isoniazid for 9 months. One month after starting isoniazid, etanercept therapy (12 weeks) for psoriasis was initiated. One month later, hepatitis B virus (HBV) markers were detected, but virological tests for active HBV were negative. Isoniazid and etanercept treatments were completed without incidence. Further clinical investigations are required to confirm the potential effects of anti-tumour necrosis factor alpha agents in such patients.

Etanercept Therapy in Patients with Psoriasis and Concomitant HCV Infection

Treatment of patients with psoriasis and/or psoriatic arthritis and concomitant hepatitis C infection remains difficult. Except for cyclosporine, other drugs have proved unacceptable because of hepatotoxicity in patients with HCV. With the advent of anti-TNF-alpha drugs, including etanercept, new therapeutic options have become available. Our study population was five patients with psoriasis and/or psoriatic arthritis and concomitant chronic HCV infection undergoing etanercept therapy. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and viral load were used as markers for liver damage and disease progression, respectively. The Psoriasis Area Severity Index (PASI) was used as a reference parameter for evaluating the therapeutic efficacy of etanercept therapy in improving the clinical skin picture. AST, ALT, viral load and PASI were monitored at 3-month intervals starting from the beginning of therapy up to two years after initiation of etanercept therapy. In four out of five patients, liver enzyme levels and viral load remained substantially unchanged during the course of therapy. In the one remaining patient, viral load and liver enzyme levels increased during etanercept therapy, and then decreased following the initiation of Peg-IFN/ribavirin in combination with anti-TNF-alpha therapy. PASI scores decreased in all five patients. Our data suggest that etanercept therapy is safe and provides an efficacious therapeutic alternative in patients with psoriasis and concomitant HCV infection.

A Case of Tumor Necrosis Factor-alpha Inhibitors-induced Pustular Psoriasis

Anti-tumor necrosis factor (TNF)-alpha agents promise better disease control for the treatment of ankylosing spondylitis resistant to classical disease-modifying treatments. Etanercept, a recombinant human TNF receptor fusion protein, is used to treat a variety of TNF-alpha-mediated diseases by inhibiting the biological activity of TNF-alpha. We experienced a case of pustular psoriasis in a 32-year-old man during anti-TNF-alpha therapy with etanercept. He had a history of ankylosing spondylitis for 2 years. Two years after treatment of etanercept, erythematous pustules developed on his palms and soles. He had no previous history of pustular psoriasis. The skin lesion improved as the etanercept therapy was stopped, but pustular skin eruption recurred as adalimumab, a different TNF-alpha inhibitor, was administered to manage his ankylosing spondylitis. Several TNF-alpha inhibitors have different molecular structures, but these inhibitors might have a similar potency to induce pustular psoriasis from this case.

Antinuclear antibodies associate with loss of response to antitumour necrosis factor-alpha therapy in psoriasis: a retrospective, observational study

BACKGROUND

An increasing number of patients with severe psoriasis are failing to respond to antitumour necrosis factor (TNF)-alpha therapy (etanercept, infliximab and adalimumab).

OBJECTIVES

We observed that many of these patients developed antinuclear antibodies (ANA) and antidouble-stranded DNA (anti-dsDNA) antibodies while on treatment prompting us to investigate whether their development is associated with anti-TNF treatment failure.

METHODS

All patients with psoriasis who had received anti-TNF therapies were identified and their blood results and treatment histories were obtained from electronic patient records and case notes.

RESULTS

A total of 97 patients had been treated with anti-TNF agents (60 were on their first agent, 22 had been on and stopped one agent, nine had been on and stopped two agents and six had been on and stopped all three agents). ANA developed in 17% of patients on their first treatment, 54% of patients who had failed one treatment, 78% of patients who had failed two treatments and 83% of patients who had failed all three treatments. Anti-dsDNA antibodies developed in 2%, 27%, 33% and 83% of patients from the same respective groups. Significantly, the antibodies developed before treatment had failed with all three agents and their development was not related to the total time that patients had been on anti-TNF therapy.

CONCLUSIONS

This study suggests that the development of ANA and anti-dsDNA antibodies on anti-TNF treatment may act as a marker of forthcoming treatment failure. Large-scale prospective studies are required to assess the importance of this observation.

Hepatitis C-associated rheumatic disorders

Hepatitis C virus (HCV) is an important causative agent of liver diseases. However, HCV infection is also associated with numerous hematologic, renal, dermatologic, rheumatic, and autoimmune disorders. These include arthralgia, arthritis, vasculitis, sicca syndrome, myalgia, and fibromyalgia. The purpose of this article is to review the prevalence and spectrum of rheumatic disorders and autoimmune phenomena in HCV-infected patients. It evaluates and current treatment options including nonsteroidal anti-inflammatory drugs, low-dose corticosteroids, hydroxychloroquine, methotrexate, penicillamine, combined antiviral therapy, cyclosporin A, anti-TNF-a agents, and rituximab. It concludes that larger, controlled studies are needed to establish further the treatment indications, efficacy, and safety of these agents.

The Safety of Anti-TNF Agents in the Elderly

Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis are commonly thought of as inflammatory diseases that affect younger individuals. Although the initial presentation of these diseases is common in a patient's twenties or thirties, they usually persist for the duration of the patient's life. In addition, up to one-third of patients with RA have disease onset after 60 years of age. Anti-TNF-a therapies now have well-recognized safety profiles that have been demonstrated in the usual clinical trial populations for these diseases, but such populations under-represent patients > or =65 years of age. This retrospective study aims to determine the safety profiles for etanercept, infliximab and adalimumab in patients of 65 years or more, undergoing anti-TNF treatment for an active inflammatory disease such as rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis, or skin disease like psoriasis. Our data show that admitting elderly patients into anti-TNF therapeutic regimens is a safe option and that it grants these patients access to the best current therapeutic option, possibly leading to better disease outcome. Quality of life in elderly patients affected by arthritis or psoriasis, often reduced by comorbidities, is as important as quality of life in younger patients. Applying the recommended screening before using biological treatment helps to reduce adverse events related to the therapy, and the application of the same screening in elderly patients seems to lead to comparable results.

Long-term efficacy of biologics in dermatology

Chronic dermatologic diseases affect millions of people. The long-term nature of these diseases creates psychological and financial burden as well as substantially impacts patients' quality of life. Biologics, including adalimumab, etanercept, alefacept, efalizumab, and infliximab, are the newest therapeutic agents in the treatment of moderate-to-severe psoriasis and psoriatic arthritis and have been used in a variety of other dermatologic diseases. These agents act relatively quickly and effectively in 12-week clinical trials. Because these agents are used to treat patients for longer than 12 weeks, there is a need to review the safety and efficacy of these agents over longer periods of time. Many levels of evidence are available for biologics including high level of evidence from large, randomized, double-blind, placebo-controlled clinical studies. This review focuses on the available data for efficacy and safety for greater than 24 weeks of therapy. The studies supporting the use of rituximab and intravenous immunoglobulin in autoimmune blistering diseases are also presented in this review.

FLT3 inhibitors for the treatment of autoimmune disease

BACKGROUND

Autoimmune diseases encompass a broad range of illnesses with a variety of underlying causes, some of which are known and some of which remain elusive.

OBJECTIVE

The focus of this review will be on describing the development of a new type of therapy that could potentially treat T cell-mediated autoimmune diseases. Unlike traditional therapies, which have primarily focused on suppressing T cells directly, targeting the step of antigen presentation may allow a less toxic therapy in which autoimmunity is lessened without compromising the entire immune system. This review will outline the science behind the development of the therapy, the roles of dendritic cells in generating autoimmune disease, and the function of the FLT3 receptor in this process.