Upadacitinib for moderate-to-severe atopic dermatitis: Stratified analysis from three randomized phase 3 trials by key baseline characteristics

BACKGROUND

Atopic dermatitis (AD) is a heterogeneous inflammatory skin disease with different clinical phenotypes based on factors such as age, race, comorbidities, and clinical signs and symptoms. The effect of these factors on therapeutic responses in AD has only been scarcely studied and not for upadacitinib. Currently, there is no biomarker predicting response to upadacitinib.

OBJECTIVES

Evaluate the efficacy of the oral Janus kinase inhibitor upadacitinib across patient subgroups (baseline demographics, disease characteristics and prior treatment) in patients with moderate-to-severe AD.

METHODS

Data from phase 3 studies (Measure Up 1, Measure Up 2 and AD Up) were utilized for this post hoc analysis. Adults and adolescents with moderate-to-severe AD were randomized to receive once daily oral upadacitinib 15 mg, upadacitinib 30 mg or placebo; patients enrolled in the AD Up study received concomitant topical corticosteroids. Data from the Measure Up 1 and Measure Up 2 studies were integrated.

RESULTS

A total of 2584 patients were randomized. A consistently greater proportion of patients achieved at least 75% improvement in the Eczema Area and Severity Index, a 0 or 1 on the validated Investigator Global Assessment for Atopic Dermatitis, and improvement in itch (including an achievement of a reduction of ≥4; and score of 0/1 in Worst Pruritus Numerical Rating Scale) with upadacitinib compared with placebo at Week 16, regardless of age, sex, race, body mass index, AD severity, body surface area involvement, history of atopic comorbidities or asthma, or previous exposure to systemic therapy or cyclosporin.

CONCLUSIONS

Upadacitinib had consistently high skin clearance rates and itch efficacy across subgroups of patients with moderate-to-severe AD through Week 16. These results support upadacitinib as a suitable treatment option in a variety of patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT03569293 (Measure Up 1), NCT03607422 (Measure Up 2) and NCT03568318 (AD Up).

Efficacy of spesolimab for the treatment of generalized pustular psoriasis flares across pre-specified patient subgroups in the Effisayil 1 study

Effisayil 1 was a multicentre, randomized, double-blind, placebo-controlled study of the anti-interleukin (IL)-36 receptor monoclonal antibody, spesolimab, in patients presenting with a generalized pustular psoriasis (GPP) flare. Previously published data from this study revealed that within 1 week, rapid pustular and skin clearance were observed in patients receiving spesolimab versus placebo. In this pre-specified subgroup analysis, the efficacy of spesolimab was evaluated according to patient demographic and clinical characteristics at baseline in patients receiving spesolimab (n = 35) or placebo (n = 18) on Day 1. Efficacy was by assessed by achievement of primary endpoint (Generalized Pustular Psoriasis Physician Global Assessment [GPPGA] pustulation subscore of 0 at Week 1) and key secondary endpoint (GPPGA total score of 0 or 1 at Week 1). Safety was assessed at Week 1. Spesolimab was found to be efficacious and had a consistent and favourable safety profile in patients presenting with a GPP flare, regardless of patient demographics and clinical characteristics at baseline.

Estimands for atopic dermatitis clinical trials: Expert opinion on the importance of intercurrent events

Despite the emergence of novel targeted treatments for atopic dermatitis (AD), there is a lack of guidelines on standardizing analysis of clinical trial data. To define and estimate meaningful treatment comparisons, several factors, including intercurrent events, must be taken into account. Intercurrent events are defined as events occurring after treatment initiation that affect either the interpretation or existence of the measurements associated with clinical questions of interest. Due to the relapsing, unpredictable nature of AD, intercurrent events frequently occur in AD trials, such as use of rescue therapy for intense itch and sleep deprivation. Despite the impact of intercurrent events in AD, they are often handled in an inconsistent manner across trials, which limits results interpretation. The estimand framework is increasingly used to estimate treatment effects while accounting for intercurrent events. This review explores how guidance from the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH) on the use of estimands can be applied to support AD clinical trial design and analysis. We propose that estimands are used in AD trials and defined early during trial design. The use of estimands can provide clinicians with interventional trial results that are more reflective of clinical practice, help facilitate comparisons across clinical trials, and are more informative to enable improved treatment selection for patients.

AB0952 Characterization of patients with psoriatic arthritis in dermatologic and rheumatologic care: an analysis of two disease registries

Background

Psoriatic arthritis (PsA) is a chronic inflammatory disease affecting the musculoskeletal system, skin and nails. Therapeutic management in Germany is usually provided by a dermatologist or rheumatologist.

Objectives

The aim is to characterize the socioeconomic and clinical patient profiles in dermatologic and rheumatologic settings.

Methods

Baseline data of patients with PsA from [1] the dermatological German Psoriasis Registry PsoBest (PB) and [2] the rheumatological German disease register RABBIT-SpA (RS) [2] were analyzed. For this purpose, comparable anamnestic and clinical variables collected in the period 10/2017 to 12/2020 were identified and descriptively analyzed. The analysis was carried out in each of the data-holding registers.

Results

1066 RS patients and 704 PB patients were included in the analysis (Table 1). The proportion of women was higher in the rheumatology setting (RS) (60% vs. 49%). Disease duration of psoriasis was longer in the dermatology setting (PB). Cutaneous severity was higher in PB, including affected body surface area and nail psoriasis. However, more patients in RS had tender joints and swollen joints. The physician-reported global disease activity was higher in RS. The mean DLQI (Dermatology Life Quality Index) was higher in PB and the mean HAQ (Health Assessment Questionnaire) was higher in RS. Patient reported global disease activity and pain were lower in PB.

Table 1.

Baseline data of patients with PsA from the registers PsoBest and RABBIT-SpA included 10/2017 to 12/2020.

RABBIT-SpA(Rheumatology setting)PsoBest(Dermatology setting)N1066704Age, mean (SD)51.9 (12.2)51.7 (13.2)Female, n (%)637 (60)346 (49)Disease duration skin, mean (SD)14.3 (13.9)21.6 (16.0)Body surface area, mean (SD)8.5 (15.0)20.8 (19.8)Nail psoriasis, n (%)434 (41)407 (58)Tender joints, n (%)905 (85)498 (71)Swollen joints, n (%)708 (67)387 (55)Physician reported disease activity, mean (SD)5.2 (1.9)4.6 (2.7)DLQI, mean (SD)5.6 (6.2)12.2 (7.6)HAQ, mean (SD)0.9 (0.7)0.7 (0.6)Patient reported disease activity, mean (SD)5.7 (2.4)4.9 (2.9)Patient reported pain, mean (SD)5.5 (2.4)5.2 (2.8)bDMARD, n (%)751 (71)514 (73)TNF, n (%)346 (46)117 (23)IL17, n (%)351 (47)246 (48)IL23, n (%)54 (7)151 (29)tsDMARD, n (%)109 (10)47 (7)csDMARD, n (%)195 (18)142 (20)

Most of the patients received biologics at inclusion (RS: 71% and PB: 73%). In the dermatology setting IL23 inhibitors were used more frequently, whereas TNF inhibitors were used more frequently in the rheumatology setting.

Conclusion

The clinical specialization of the treating physician was associated with a different treatment and clinical status of patients with PsA. Our analysis showed that patients in the rheumatology setting more frequently had joint affections and lower functional status, whereas skin severity was worse in the dermatology setting, indicating selection effects of health care access. We hypothesize out that these differences may be biased due to different diagnostic and therapeutic routines in the specialized health care settings. Psoriatic arthritis should be treated in a multidisciplinary approach to take into account all facets of this complex disease.

References

[1]PMID: 24393314

[2]PMID: 30874933

Disclosure of Interests

Lisa Lindner Grant/research support from: RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB and Viatris., Matthias Augustin Grant/research support from: The PsoBest registry is/was supported by AbbVie, Almirall Hermal, Amgen, Biogen, BMS, Celgene, Hexal, Janssen-Cilag, LEO Pharma, Eli Lilly, Medac, Novartis, Pfizer, UCB and Viatris. These companies do not have influence on the design of the registry, data collection, analyses, the publication decisions or development., Laura Kühl Grant/research support from: The PsoBest registry is/was supported by AbbVie, Almirall Hermal, Amgen, Biogen, BMS, Celgene, Hexal, Janssen-Cilag, LEO Pharma, Eli Lilly, Medac, Novartis, Pfizer, UCB and Viatris. These companies do not have influence on the design of the registry, data collection, analyses, the publication decisions or development., Anja Weiß Grant/research support from: RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB and Viatris., Stephan Jeff Rustenbach Grant/research support from: The PsoBest registry is/was supported by AbbVie, Almirall Hermal, Amgen, Biogen, BMS, Celgene, Hexal, Janssen-Cilag, LEO Pharma, Eli Lilly, Medac, Novartis, Pfizer, UCB and Viatris. These companies do not have influence on the design of the registry, data collection, analyses, the publication decisions or development., Frank Behrens: None declared, Martin Feuchtenberger: None declared, Ilka Schwarze: None declared, Ulrich Mrowietz: None declared, Diamant Thaçi: None declared, Kristian Reich Grant/research support from: The PsoBest registry is/was supported by AbbVie, Almirall Hermal, Amgen, Biogen, BMS, Celgene, Hexal, Janssen-Cilag, LEO Pharma, Eli Lilly, Medac, Novartis, Pfizer, UCB and Viatris. These companies do not have influence on the design of the registry, data collection, analyses, the publication decisions or development., Anja Strangfeld Grant/research support from: RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB and Viatris., Anne Regierer Grant/research support from: RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB and Viatris.

AB0890 Deucravacitinib, an Oral, Selective Tyrosine Kinase 2 Inhibitor, in Moderate to Severe Plaque Psoriasis: 52-Week Efficacy Results From the Phase 3 POETYK PSO-1 and POETYK PSO-2 Trials

Background

Tyrosine kinase 2 (TYK2) is an intracellular kinase that mediates signaling of key cytokines (eg, interleukin [IL]-23 and Type I interferons) involved in the pathogenesis of immune-mediated diseases including plaque psoriasis and psoriatic arthritis (PsA). Deucravacitinib is a novel, oral, selective, allosteric inhibitor of TYK2 that achieves high selectivity by uniquely binding to the regulatory domain of the enzyme, rather than to the more conserved active domain. Deucravacitinib showed superior efficacy compared with placebo at 16 weeks in a Phase 2 trial in patients with PsA (NCT03881059). Results from the 16-week, placebo-controlled periods of two 52-week, Phase 3 trials in psoriasis (POETYK PSO-1 and POETYK PSO-2) previously showed that deucravacitinib was significantly more efficacious than placebo and apremilast based on the coprimary endpoints of ≥75% reduction from baseline in Psoriasis Area and Severity Index (PASI 75) and a static Physician’s Global Assessment (sPGA) score of 0 or 1 (clear or almost clear) at Week 16.

Objectives

To evaluate the efficacy of deucravacitinib over 52 weeks in the POETYK PSO-1 and POETYK PSO-2 trials.

Methods

POETYK PSO-1 (NCT03624127) and PSO-2 (NCT03611751) were double-blinded trials that randomised patients with moderate to severe plaque psoriasis (body surface area involvement ≥10%, PASI ≥12, sPGA score ≥3) 2:1:1 to deucravacitinib 6 mg once daily, placebo, or apremilast 30 mg twice daily. Patients receiving placebo were switched to deucravacitinib at Week 16 in both trials. Patients randomised to deucravacitinib in PSO-1 received deucravacitinib continuously through Week 52. PSO-2 included a randomised withdrawal phase in which patients originally randomised to deucravacitinib who had achieved PASI 75 response at Week 24 were rerandomised 1:1 to placebo or deucravacitinib, whereas those who did not achieve PASI 75 response at Week 24 continued receiving deucravacitinib. The proportions of patients achieving PASI 75 and sPGA 0/1 responses were evaluated up to Week 52. Secondary efficacy endpoints evaluated over this period included PASI 90, PASI 100, percentage change from baseline in PASI, sPGA 0 (clear), change from baseline in the Psoriasis Symptoms and Signs Diary (PSSD) symptom score, and Dermatology Life Quality Index (DLQI) 0/1 (no impact on patient’s life).

Results

A total of 666 and 1020 patients were randomised in PSO-1 and PSO-2, respectively. Demographic and baseline disease characteristics were balanced across treatment groups; mean age was 46.6 years, mean disease duration was 18.6 years, 18.4% of patients had PsA, and 34.8% had previously used biologic therapy. PASI 75, PASI 90, and PASI 100 responses were maintained from Week 16 to Week 52 in PSO-1 (Figure 1). Additionally, sPGA responses were maintained during this period (sPGA 0/1: 53.6% to 52.7%; sPGA 0: 17.5% to 23.5%, respectively). Patients who switched from placebo to deucravacitinib at Week 16 demonstrated PASI 75 and sPGA 0/1 responses at Week 52 (68.3% and 53.8%, respectively) comparable to those observed in patients who received continuous deucravacitinib treatment from Day 1 (65.1% and 52.7%, respectively). In PSO-2, among deucravacitinib-treated patients who achieved PASI 75 at Week 24 and were rerandomised to continue treatment, responses were maintained at Week 52 in the majority of patients (PASI 75, 80.4% [119/148]; sPGA 0/1, 70.3% [83/118]). Results for percentage change from baseline in PASI, change from baseline in the PSSD symptom score, and DLQI 0/1 were consistent with those reported for PASI and sPGA responses.

Conclusion

Results from the Phase 3 POETYK PSO-1 and PSO-2 trials demonstrated that deucravacitinib was efficacious through 52 weeks in patients with moderate to severe plaque psoriasis. Clinical responses were maintained in patients who received continuous deucravacitinib treatment and were improved in patients who switched from placebo at Week 16 to deucravacitinib treatment.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Julianne Hatfield, PhD at Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, USA, and funded by Bristol Myers Squibb.

Disclosure of Interests

Richard B. Warren Consultant of: Consulting fees: AbbVie, Almirall, Amgen, Biogen, Boehringer Ingelheim, Celgene, DiCE, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, Sanofi, UCB, Biogen, and UNION., Grant/research support from: Research grants: AbbVie, Almirall, Amgen, Celgene, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, and UCB;, April Armstrong Grant/research support from: Grants and personal fees: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Leo Pharma, and Novartis; Personal fees: Boehringer Ingelheim/Parexel, Celgene, Dermavant, Genentech, GlaxoSmithKline, Menlo Therapeutics, Merck, Modernizing Medicine, Ortho Dermatologics, Pfizer, Regeneron, Sanofi Genzyme, Science 37, Sun Pharma, and Valeant; Grants: Dermira, Kyowa Hakko Kirin, and UCB, outside the submitted work., Melinda Gooderham Consultant of: Advisory board, principal investigator, and lecture fees: Arcutis, Galderma, Leo Pharma, Pfizer, and Regeneron; Principal investigator and consulting fees: Akros Pharma and Kyowa Kirin; Advisory board, principal investigator, lecture fees, and consulting fees: AbbVie, Amgen, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen, Novartis, Sanofi Genzyme, and Valeant; Principal investigator: Aslan, Bristol Myers Squibb, Dermavant, Dermira, GlaxoSmithKline, MedImmune, Merck, Roche Laboratories, and UCB., Bruce Strober Consultant of: Consultant (honoraria): AbbVie, Almirall, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim, Immunic Therapeutics, Bristol Myers Squibb, Connect Biopharma, Dermavant, Eli Lilly, Equillium, Janssen, Leo Pharma, Maruho, Meiji Seika Pharma, Mindera, Novartis, Pfizer, GlaxoSmithKline, Ortho Dermatologics, Regeneron, Sanofi Genzyme, Sun Pharma, UCB, Ventyxbio, and vTv Therapeutics; Speaker: AbbVie, Eli Lilly, Janssen, and Sanofi Genzyme; Co-Scientific Director (consulting fee): CorEvitas’ Psoriasis Registry; Investigator: AbbVie, Cara, CorEvitas’ Psoriasis Registry, Dermavant, Dermira, and Novartis., Diamant Thaçi Speakers bureau: Advisory board, principal investigator, and lecture fees: AbbVie, Almirall, Amgen, Biogen Idec, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, DS Pharma, Eli Lilly, Galapagos, Galderma, Janssen-Cilag, Leo Pharma, Novartis, Pfizer, Regeneron, Roche-Posay, Samsung, Sandoz-Hexal, Sanofi, and UCB., Shinichi Imafuku Grant/research support from: Grants and personal fees: AbbVie, Eisai, Kyowa Kirin, Taiho, Maruho, Tanabe Mitsubishi, Leo Pharma, Janssen, Sun Pharma, Torii, and Yakuhin; Personal fees: Amgen, Bristol Myers Squibb, Daiichi Sankyo, Eli Lilly, Novartis, and UCB., Howard Sofen Consultant of: Clinical Investigator: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Janssen, Leo Pharma, Novartis, and Sun Pharma., Lynda Spelman Consultant of: Consultant, paid investigator, and/or speaker: AbbVie, Amgen, Anacor, Ascend, Astellas, AstraZeneca, Blaze Bioscience, Boehringer Ingelheim, Botanix, Bristol Myers Squibb, Celgene, Dermira, Eli Lilly, Galderma, Genentech, GlaxoSmithKline, Hexima, Janssen, Leo Pharma, Mayne, Medimmune, Merck, Merck-Serono, Novartis, Otsuka, Pfizer, Phosphagenics, Photon MD, Regeneron, Roche, Samumed, Sanofi Genzyme, SHR, Sun Pharma, Trius, UCB, and Zai Lab., Neil J Korman Speakers bureau: Advisory board, consulting fees: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Leo Pharma, Novartis, Principia, Regeneron, Sanofi Genzyme, Sun Pharma, and UCB; Speaker: AbbVie, Eli Lilly, Janssen, Novartis, Regeneron, and Sanofi Genzyme., Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Leo Pharma, Novartis, Principia, Regeneron, Sanofi Genzyme, Sun Pharma, and UCB, Grant/research support from: Grant support/principal investigator: AbbVie, Amgen, Argenx, Bristol Myers Squibb, Celgene, Chemocentryx, Eli Lilly, Galderma, Kyowa Hakko Kirin, Leo Pharma, Menlo, Principia, Prothena, Rhizen, Syntimmune, Trevi, and Xbiotech., Min Zheng Speakers bureau: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly China, Leo Pharma China, Novartis China, Pfizer, Sanofi China, and Xian-Janssen., Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly China, Leo Pharma China, Novartis China, Pfizer, Sanofi China, and Xian-Janssen., Grant/research support from: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly China, Leo Pharma China, Novartis China, Pfizer, Sanofi China, and Xian-Janssen., Elizabeth Colston Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, John Throup Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sudeep Kundu Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Renata Kisa Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Employees and shareholders: Bristol Myers Squibb, Employee of: Employees and shareholders: Bristol Myers Squibb, Andrew Blauvelt Consultant of: Scientific advisor and/or clinical study investigator: AbbVie, Abcentra, Aligos, Almirall, Amgen, Arcutis, Arena, Aslan, Athenex, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, EcoR1, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Landos, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sanofi Genzyme, Sun Pharma, UCB, and Vibliome. 

Quality of life and patient-perceived symptoms in patients with psoriasis undergoing proactive or reactive management with the fixed-dose combination Cal/BD foam: A post-hoc analysis of PSO-LONG

Background

Psoriasis has important physical and psychosocial effects that extend beyond the skin. Understanding the impact of treatment on health‐related quality of life (HRQoL) and patient‐perceived symptom severity in psoriasis is key to clinical decision‐making.

Objectives

This post hoc analysis of the PSO‐LONG trial data assessed the impact of long‐term proactive or reactive management with fixed‐dose combination calcipotriene 50 µg/g and betamethasone dipropionate 0.5 mg/g (Cal/BD) foam on patient‐reported outcomes (PROs) in patients with psoriasis vulgaris.

Methods

Five hundred and twenty‐one patients from the Phase 3, randomized, double‐blind PSO‐LONG trial were included. An initial 4‐week, open‐label phase of fixed‐dose combination Cal/BD foam once daily (QD) was followed by a 52‐week maintenance phase, at the start of which patients were randomized to a proactive management arm (Cal/BD foam twice weekly) or reactive management arm (vehicle foam twice weekly). Patient‐perceived symptom severity and HRQoL were assessed using the Psoriasis Symptom Inventory (PSI), the Dermatology Life Quality Index (DLQI) and the EuroQol‐5D for psoriasis (EQ‐5D‐5L‐PSO).

Results

Statistically and clinically significant improvements were observed across all PRO measures. The mean difference (standard deviation) from baseline to Week 4 was −8.97 (6.18) for PSI, −6.02 (5.46) for DLQI and 0.11 (0.15) for EQ‐5D‐5L‐PSO scores. During maintenance, patients receiving reactive management had significantly higher DLQI (15% [p = 0.007]) and PSI (15% [p = 0.0128]) and a numerically lower EQ‐5D‐5L‐PSO mean area under the curve score than patients receiving proactive management (1% [p = 0.0842]).

Conclusions

Cal/BD foam significantly improved DLQI, EQ‐5D‐5L‐PSO and PSI scores during the open‐label and maintenance phases. Patients assigned to proactive management had significantly better DLQI and PSI scores and numerically better EQ‐5D‐5L‐PSO versus reactive management. Additionally, baseline flare was associated with worse PROs than the start of a relapse, and patients starting a relapse also had worse PROs than patients in remission.

POS1042 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE TYROSINE KINASE 2 (TYK2) INHIBITOR, COMPARED WITH PLACEBO AND APREMILAST IN MODERATE TO SEVERE PLAQUE PSORIASIS: RESULTS FROM THE PHASE 3 POETYK PSO-1 STUDY

Background:

Tyrosine kinase 2 (TYK2) is an intracellular kinase that mediates interleukin (IL)-23, IL-12, and interferon (IFN)α/β signaling. Deucravacitinib is a novel, oral, selective inhibitor of TYK2 acting via binding to the TYK2 regulatory domain.1 Phase 2 results showed deucravacitinib was efficacious and well tolerated versus placebo in patients with moderate to severe plaque psoriasis or active psoriatic arthritis.2,3 No herpes zoster infections, opportunistic infections, thromboembolic events, or hematologic or lipid abnormalities characteristic of Janus kinase (JAK) 1−3 inhibitors were reported in the Phase 2 trials.2,3

Objectives:

To compare the efficacy and safety of deucravacitinib versus placebo and apremilast in plaque psoriasis.

Methods:

This Phase 3, double-blinded, 52-week study (NCT03624127) randomized patients with moderate to severe plaque psoriasis (BSA ≥10%, PASI ≥12, sPGA ≥3) to deucravacitinib 6 mg once daily, placebo, or apremilast 30 mg twice daily (2:1:1). Patients receiving placebo were switched to deucravacitinib at Week 16; apremilast-treated patients not achieving PASI 50 at Week 24 were switched to deucravacitinib. Coprimary endpoints were PASI 75 and sPGA 0/1 response versus placebo at Week 16. Key secondary endpoints included superiority versus apremilast, assessed via multiple measures.

Results:

666 patients were randomized. Demographic and baseline disease characteristics were balanced across groups; mean age was 46.1 years, mean disease duration was 17.3 years, 18.2% of patients had psoriatic arthritis at baseline, and 38.9% had previously used biologic therapy. Mean BSA involvement at baseline was 26.3%, mean PASI was 21.4, and the percentage with severe sPGA (score=4) at baseline was 21.2%. Significantly greater proportions of patients in the deucravacitinib versus placebo and apremilast arms achieved PASI 75 (58.7% vs 12.7% vs 35.1%, respectively; P<0.0001) and sPGA 0/1 (53.6% vs 7.2% vs 32.1%, respectively; P<0.0001) response at Week 16 (Figure 1). Deucravacitinib was also superior to apremilast at Week 24, with 69.0% versus 38.1% of patients achieving PASI 75 and 58.4% versus 31.0% achieving sPGA 0/1 (P<0.0001 for both). In addition, DLQI 0/1 responses at Week 16 were significantly higher with deucravacitinib versus placebo and apremilast, demonstrating improved quality of life (40.7% vs 10.6% vs 28.6%, respectively; Figure 1). During the 16-week, placebo-controlled period, the most common AEs (≥5% in any arm) were nasopharyngitis, upper respiratory tract infection, headache, diarrhea, and nausea (Table 1). Frequencies of SAEs and treatment discontinuations due to AEs were low (Table 1).

Table 1.

Summary of adverse events (AEs) through Week 16

Patients, n (%)Deucravacitinibn=332Placebon=165Apremilastn=168Any AEs176 (53.0)70 (42.4)93 (55.4)Severe AEs5 (1.5)7 (4.2)5 (3.0)Serious AEs7 (2.1)9 (5.5)4 (2.4)AEs leading to treatment discontinuation6 (1.8)7 (4.2)10 (6.0)Most common AEs (≥5% in any arm) Nasopharyngitis21 (6.3)7 (4.2)14 (8.3) Upper respiratory tract infection21 (6.3)6 (3.6)3 (1.8) Headache16 (4.8)5 (3.0)17 (10.1) Diarrhea13 (3.9)6 (3.6)17 (10.1) Nausea7 (2.1)4 (2.4)19 (11.3)

Conclusion:

Deucravacitinib demonstrated superiority versus placebo and apremilast across multiple efficacy endpoints in patients with moderate to severe plaque psoriasis, and was generally well tolerated. Overall, the efficacy and safety profile of deucravacitinib was consistent with that observed in the Phase 2 plaque psoriasis and psoriatic arthritis trials.2,3

References:

[1]Burke JR et al. Sci Transl Med. 2019;11:1-16.

[2]Papp K et al. N Engl J Med. 2018;379:1313-21.

[3]Mease PJ et al. Presented at: Annual Scientific Meeting of the American College of Rheumatology; November 5-9, 2020; Virtual meeting.

Acknowledgements:

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Peloton Advantage, LLC, an OPEN Health company, and funded by Bristol Myers Squibb.

Disclosure of Interests:

April Armstrong Consultant of: Grants and personal fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Leo Pharma, Novartis; Personal fees from Boehringer Ingelheim/Parexel, Celgene, Dermavant, Genentech, GlaxoSmithKline, Menlo Therapeutics, Merck, Modernizing Medicine, Ortho Dermatologics, Pfizer, Regeneron, Sanofi Genzyme, Science 37, Sun Pharma, Valeant, Grant/research support from: Grants: Dermira, Kyowa Hakko Kirin, and UCB, outside the submitted work; Grants and personal fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Leo Pharma, Novartis, Melinda Gooderham Shareholder of: Speakers bureau, consultant, investigator/advisor: AbbVie, Akros, Amgen, Arcutis, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Dermira, Eli Lilly, Galderma, GlaxoSmithKline, Incyte, Janssen, Kyowa Hakko Kirin, Leo Pharma, Merck, MedImmune, Novartis, Pfizer, Regeneron, Roche, Sanofi Genzyme, Takeda, UCB, Valeant, Richard B. Warren Consultant of: AbbVie, Almirall, Amgen, Boehringer Ingelheim, Celgene, Janssen, Leo Pharma, Eli Lilly, Novartis, Pfizer, Sanofi, Xenoport, UCB, Grant/research support from: AbbVie, Almirall, Amgen, Celgene, Janssen, Eli Lilly, Leo Pharma, Novartis, Pfizer, UCB, Kim Papp Speakers bureau: AbbVie, Amgen, Astellas, Celgene, Eli Lilly, Galderma, Janssen, Kyowa Hakko Kirin, Leo Pharma, Merck Sharp & Dohme, Novartis, Pfizer, Valeant, Consultant of: Scientific officer/steering committee/advisory board: AbbVie, Akros, Amgen, Anacor, Astellas, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Dow Pharma, Eli Lilly, Galderma, Janssen, Kyowa Hakko Kirin, Merck Sharp & Dohme, Merck Serono, Novartis, Pfizer, Regeneron, Sanofi-Aventis/Genzyme, Valeant, Grant/research support from: AbbVie, Akros, Allergan, Amgen, Anacor, Arcutis, AstraZeneca, Baxalta, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Coherus, Dermira, Dow Pharma, Eli Lilly, Galderma, Genentech, GlaxoSmithKline, Janssen, Kyowa Hakko Kirin, Leo Pharma, MedImmune, Meiji Seika Pharma, Merck Serono, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis/Genzyme, Takeda, UCB, Valeant;

Consultant: AbbVie, Akros, Amgen, Arcutis, Astellas, AstraZeneca, Baxalta, Baxter, Boehringer Ingelheim, Bristol Myers Squibb, CanFite, Celgene, Coherus, Dermira, Dow Pharma, Eli Lilly, Forward Pharma, Galderma, Genentech, Janssen, Kyowa Hakko Kirin, Leo Pharma, Meiji Seika Pharma, Merck Sharp & Dohme, Merck Serono, Mitsubishi Pharma, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis/Genzyme, Takeda, UCB, Valeant; Honoraria: AbbVie, Akros, Amgen, Baxter, Boehringer Ingelheim, Celgene, Coherus, Eli Lilly, Forward Pharma, Galderma, GlaxoSmithKline, Janssen, Kyowa Hakko Kirin, Merck Sharp & Dohme, Merck Serono, Novartis, Pfizer, Takeda, UCB, Valeant, Bruce Strober Speakers bureau: AbbVie, Janssen, Eli Lilly, Ortho Dermatologics, Consultant of: Honoraria or consultation fees: AbbVie, Almirall, Amgen, Arena, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Dermavant, Dermira, Eli Lilly, GSK, Janssen, Kyowa Hakko Kirin, Leo Pharma, Medac, Meiji Seika Pharma, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB; Scientific Director (consulting fee): Corrona Psoriasis Registry; Investigator: AbbVie, Corrona Psoriasis Registry, Dermavant, Dermira., Diamant Thaçi Paid instructor for: Lectures: AbbVie, Almirall, Amgen, DS-Pharma, Janssen, Leo Pharma, MSD, Novartis, Pfizer, Roche-Posay, Sandoz-Hexal, Sanofi, Target-Solution, UCB; Scientific advisory board: AbbVie, Amgen, Celgene, DS Pharma, Eli Lilly, Galapagos, Janssen-Cilag, Leo Pharma, Morphosis, MSD Novartis, Pfizer, Sandoz, Sanofi, UCB., Consultant of: Consultant: AbbVie, Almirall, Celgene, Dignity, Galapagos, Leo Pharma, Maruho, Mitsubishi, Novartis, Pfizer, Xenoport, Grant/research support from: Research support/principal investigator (clinical trials): AbbVie, Almirall, Amgen, Biogen Idec, Boehringer Ingelheim, Celgene, Chugai, Dermira, DS-Pharma, Eli Lilly, Galderma, GSK, Janssen-Cilag, Leo, MSD, Novartis, Pfizer, Regeneron, Roche, Sandoz-Hexal, Sanofi, UCB, Elizabeth Colston Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, John Throup Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sudeep Kundu Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Andrew Blauvelt Consultant of: Scientific adviser and/or clinical study investigator for AbbVie, Aligos, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sanofi Genzyme, Sun Pharma, UCB Pharma.

Direct comparison of risankizumab and fumaric acid esters in systemic therapy-naïve patients with moderate-to-severe plaque psoriasis: a randomized controlled trial

Background

Fumaric acid esters (FAEs; Fumaderm^®) are the most frequently prescribed first‐line systemic treatment for moderate‐to‐severe plaque psoriasis in Germany. Risankizumab (Skyrizi^®) is a humanized IgG1 monoclonal antibody that specifically binds to the p19 subunit of interleukin 23.

Objectives

To compare risankizumab treatment to FAEs in patients with psoriasis.

Methods

This phase III randomized, active‐controlled, open‐label study with blinded assessment of efficacy was conducted in Germany. Patients were randomized (1 : 1) to subcutaneous risankizumab 150 mg (weeks 0, 4 and 16) or oral FAEs at increasing doses from 30 mg daily (week 0) up to 720 mg daily (weeks 8–24). Enrolled patients were adults naïve to and candidates for systemic therapy, with chronic moderate‐to‐severe plaque psoriasis. Phototherapy was not allowed within 14 days before or during the study.

Results

Key efficacy endpoints were met at week 24 for risankizumab (n = 60) vs. FAEs (n = 60) (P < 0·001): achievement of a ≥ 90% improvement in Psoriasis Area and Severity Index (PASI; primary endpoint 83·3% vs. 10·0%), ≥ 100% improvement in PASI (50·0% vs. 5·0%), ≥ 75% improvement in PASI (98·3% vs. 33·3%), ≥ 50% improvement in PASI (100% vs. 53·3%) and a Static Physician’s Global Assessment of clear/almost clear (93·3% vs. 38·3%). The rates of gastrointestinal disorders, flushing, lymphopenia and headache were higher in the FAE group. One patient receiving risankizumab reported a serious infection (influenza, which required hospitalization). There were no malignancies, tuberculosis or opportunistic infections in either treatment arm.

Conclusions

Risankizumab was found to be superior to FAEs, providing earlier and greater improvement in psoriasis outcomes that persisted with continued treatment, and more favourable safety results, which is consistent with the known safety profile. No new safety signals for risankizumab or FAEs were observed.

What is already known about this topic?

Risankizumab (Skyrizi^®) is approved as treatment for patients with moderate‐to‐severe plaque psoriasis who are candidates for systemic therapy.

Risankizumab is a humanized IgG1 monoclonal antibody that specifically binds to the p19 subunit of interleukin 23.

Fumaric acid esters (FAEs) are the most frequently prescribed first‐line systemic treatment for moderate‐to‐severe plaque psoriasis in Germany.

What does this study add?

In patients with psoriasis who were naïve to systemic treatment, risankizumab treatment was superior to FAEs, providing earlier and greater improvement in psoriasis outcomes that persisted to week 24.

Risankizumab showed more favourable safety results than FAEs and no new safety signals.

The results support risankizumab treatment for patients with moderate‐to‐severe plaque psoriasis who are naïve to systemic treatment.

Linked Comment: P. Fleming. Br J Dermatol 2022; 186:4–5.

Plain language summary available online

Addressing challenges associated with long-term topical treatment and benefits of proactive management in patients with psoriasis

The majority of patients with psoriasis vulgaris (chronic plaque psoriasis) can be treated successfully with short‐term topical therapies. However, long‐term management of psoriasis with topicals is challenging and tends to take a reactive approach to disease relapse, rather than a proactive approach aimed at maintaining disease remission. Patients are often dissatisfied with the delay in treatment response and inconvenience of applying topical treatments, and therefore frequently discontinue treatment leading to poor outcomes. Relapse is common, particularly with reactive management, as underlying residual disease can remain following initial skin clearance; some patients find that their disease at relapse may be worse than their initial symptoms. This can have a detrimental effect on patient quality of life (QoL) and increase the risk of psoriasis‐associated depression. A long‐term proactive management approach, with maintenance treatment following initial treatment success, could help sustain disease remission and improve clinical and QoL outcomes for patients. Treatment with fixed‐dose calcipotriol 50 µg/g betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) is effective in the short term, providing a fast onset of action and improvements in disease at 4 weeks. Results from the Phase III PSO‐LONG study demonstrated that long‐term proactive management was superior to reactive management in prolonging time to first relapse, reducing number of relapses and increasing days in remission in adults with psoriasis vulgaris. Furthermore, Cal/BD foam was well tolerated in PSO‐LONG. No new safety concerns were identified over 52 weeks; the safety profile was consistent with that described previously. Given this, Cal/BD foam should be considered when prescribing topicals for the long‐term proactive management for patients with psoriasis.

Video abstract

Association of sex and systemic therapy treatment outcomes in psoriasis: a two-country, multicentre, prospective, noninterventional registry study

BACKGROUND

Few systematic data on sex-related treatment responses exist for psoriasis.

OBJECTIVES

To evaluate sex differences with respect to systemic antipsoriatic treatment.

METHODS

Data from patients with moderate-to-severe psoriasis in the PsoBest or Swiss Dermatology Network of Targeted Therapies (SDNTT) registries were analysed. Treatment response was defined as achieving a ≥ 75% reduction in Psoriasis Area and Severity Index (PASI 75) or PASI ≤ 3 at treatment months 3, 6 and 12, supplemented by patient-reported outcomes [i.e. Dermatology Life Quality Index (DLQI) ≤ 1 and delta DLQI ≥ 4].

RESULTS

In total, 5346 patients registered between 2007 and 2016 were included (PsoBest, n = 4896; SDNTT, n = 450). The majority received nonbiological treatment (67·3% male, 69·8% female). Women showed slightly higher PASI response rates after 3 (54·8% vs. 47·2%; P ≤ 0·001), 6 (70·8% vs. 63·8%; P ≤ 0·001) and 12 months (72·3% vs. 66·1%; P ≤ 0·004). A significantly higher proportion of women achieved a reduction in DLQI ≥ 4 [month 3: 61·4% vs 54·8% (P ≤ 0·001); month 6: 69·6% vs. 62·4% (P ≤ 0·001); month 12: 70·7% vs. 64·4% (P ≤ 0·002)]. Regarding PASI ≤ 3, women on biologics showed a significantly superior treatment response compared with men at 3 (57·8% vs. 48·5%; P ≤ 0·004) and 6 months (69·2% vs. 60·9%; P ≤ 0·018). Women in the nonbiological treatment group had a significantly better treatment response (PASI response, PASI 75 and PASI ≤ 3) over 12 months compared with men.

CONCLUSIONS

We provide evidence that women experience better treatment outcomes with systemic antipsoriatic therapy than men.

Patient-reported outcomes with risankizumab versus fumaric acid esters in systemic therapy-naïve patients with moderate to severe plaque psoriasis: a phase 3 clinical trial

BACKGROUND

In a phase 3 clinical study, patients from Germany with moderate to severe psoriasis who were naïve to systemic treatment and received risankizumab had greater and more rapid disease improvements compared with those who received fumaric acid esters (FAEs).

OBJECTIVE

To evaluate patient-reported outcomes (PROs) in patients treated with risankizumab compared with FAEs.

METHODS

Adult patients were randomized 1:1 to receive either risankizumab 150 mg subcutaneous injections at weeks 0, 4 and 16 or FAEs (Fumaderm^® ) provided according to the prescribing label. PRO secondary endpoints assessed were Psoriasis Symptom Scale (PSS), Dermatology Life Quality Index (DLQI), 36-Item Short Form Health Survey, version 2 (SF-36v2), Patient Benefit Index (PBI), Hospital Anxiety and Depression Scale (HADS), Patient Global Assessment (PtGA) and European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L). PROs were assessed at weeks 0, 16 and 24.

RESULTS

Sixty patients each were randomized to receive risankizumab or FAEs. A significant PSS improvement was observed with risankizumab vs. FAEs at weeks 16 and 24 for total and psoriasis-associated redness, itching and burning scores (P < 0.001). DLQI scores were significantly lower (reflecting better health-related quality of life) with risankizumab vs. FAEs, with least squares (LS) mean differences of -7.4 and -7.6 at weeks 16 and 24, respectively (both P < 0.001). Patients randomized to risankizumab also had larger improvements in SF-36 Physical and Mental Component Summary scores, HADS anxiety and depression scores, PtGA, and EQ-5D-5L index and visual analogue scale scores (all P ≤ 0.002) at weeks 16 and 24 compared with FAEs. PBI was significantly higher, indicating greater benefit, with risankizumab vs. FAEs, with an LS mean difference of 1.1 and 1.3 at weeks 16 and 24, respectively (both P < 0.001).

CONCLUSIONS

Risankizumab provides significant benefits over FAEs in improving PROs across several dimensions in patients with moderate to severe psoriasis.

International observational atopic dermatitis cohort to follow natural history and treatment course: TARGET-DERM AD study design and rationale

INTRODUCTION

As new topical and systemic treatments become available for atopic dermatitis (AD), there is a need to understand how treatments are being used in routine clinical practice, their comparative effectiveness and their long-term safety in diverse clinical settings.

METHODS AND ANALYSIS

The TARGET-DERM AD cohort is a longitudinal, observational study of patients with AD of all ages, designed to provide practical information on long-term effectiveness and safety unobtainable in traditional registration trials. Patients with physician-diagnosed AD receiving prescription treatment (topical or systemic) will be enrolled at academic and community clinical centres. Up to 3 years of retrospective medical records, 5 years of prospective medical records, and optional biological samples and patient-reported outcomes will be collected. The primary aims include characterisation of AD treatment regimens, evaluation of response to therapy, and description of adverse events.

ETHICS AND DISSEMINATION

TARGET-DERM has been approved by a central IRB (Copernicus Group IRB, 5000 Centregreen Way Suite 200, Cary, North Carolina 27513) as well as local and institutional IRBs. No additional Ethics Committee reviews. Results will be reviewed by a publications committee and submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03661866, pre-results.

Patients with bullous pemphigoid and comorbid psoriasis present with less blisters and lower serum levels of anti-BP180 autoantibodies

BACKGROUND

Although the association of bullous pemphigoid (BP) and psoriasis is well-established, the clinical and immunological features of patients with coexisting BP and psoriasis are yet to be investigated.

OBJECTIVE

We aimed to estimate the prevalence of psoriasis amongst patients with BP and to elucidate the clinical and immunological characteristics of BP patients with comorbid psoriasis.

METHODS

A retrospective cohort study including all consecutive patients diagnosed with BP throughout the years 2009-2019 in a tertiary referral centre.

RESULTS

The study encompassed 273 patients with BP, of whom 11 (4.0%; 95% CI, 2.3-7.1%) had comorbid psoriasis. The onset of psoriasis preceded that of BP in 81.8% of patients by a median (range) latency of 26.5 (5.0-34.0) years. Compared to BP patients without psoriasis, those with BP and comorbid psoriasis were significantly younger at the onset of BP [71.8 (9.3) vs. 79.4 (9.8) years; P = 0.023], had a milder erosive phenotype [erosion/blister BPDAI mean (SD)score; 5 (4.1) vs. 22.3 (15.2); P = 0.025], lower levels of anti-BP180 NC16A serum autoantibodies [236.6 (266.3) vs. 556.2 (1323.6) U/mL; P = 0.008] and a higher prevalence of isolated linear C3 deposits (36.4% vs. 14.1%; P = 0.043) and a lower prevalence of linear immunoglobulin G deposits (36.4% vs. 68.7%; P = 0.025) along the dermal-epidermal junction by direct immunofluorescence microscopy.

CONCLUSIONS

Patients with BP and comorbid psoriasis present at a younger age with milder erosive phenotype and lower levels of pathogenic autoantibodies.

Dupilumab provides favourable long-term safety and efficacy in children aged ≥ 6 to < 12 years with uncontrolled severe atopic dermatitis: results from an open-label phase IIa study and subsequent phase III open-label extension study

Background

Children aged ≥ 6 to < 12 years with severe atopic dermatitis (AD) have limited treatment options. In a 16‐week, randomized, placebo‐controlled, phase III trial in children, dupilumab, a monoclonal antibody inhibiting interleukin (IL)‐4/IL‐13 signalling, significantly improved signs and symptoms with acceptable safety; longer‐term safety and efficacy data are lacking.

Objectives

To report the pharmacokinetic profile and long‐term safety and efficacy of dupilumab in children (aged ≥ 6 to < 12 years) with severe AD.

Methods

Children (aged ≥ 6 to < 12 years) with severe AD were enrolled in a global, multicentre, phase IIa, open‐label, ascending‐dose, sequential cohort study and subsequent open‐label extension (OLE) study. Patients received single‐dose dupilumab 2 or 4 mg kg⁻¹ followed by 8‐week pharmacokinetic sampling, then 2 or 4 mg kg⁻¹ weekly for 4 weeks (phase IIa), followed by the same weekly regimen (OLE). Primary endpoints were dupilumab concentration–time profile and treatment‐emergent adverse events (TEAEs); secondary assessments included Eczema Area and Severity Index (EASI) and Peak Pruritus Numeric Rating Scale (PP‐NRS) score.

Results

Of 38 children enrolled, 37 completed phase IIa and 33 continued to the OLE. Nonlinear, target‐mediated pharmacokinetics characterized dupilumab concentrations (week 24–48 mean serum concentrations: 2 mg kg⁻¹, 61–77 mg L⁻¹; 4 mg kg⁻¹, 143–181 mg L⁻¹). TEAEs were mostly mild to moderate and transient; none led to treatment discontinuation. The most commonly reported TEAEs were nasopharyngitis (2 mg kg⁻¹, 47%; 4 mg kg⁻¹, 56%) and AD exacerbation (29% and 13%, respectively). Single‐dose dupilumab rapidly improved AD with further improvements through week 52. Mean EASI and PP‐NRS improved by −37%/−33% and −17%/−20% at week 2 (phase IIa) and −92%/−84% and −70%/−58% at week 52 (OLE), respectively.

Conclusions

These safety and efficacy results support the use of dupilumab as a continuous long‐term treatment for children aged ≥ 6 to < 12 years with severe AD.

What is already known about this topic?

Severe atopic dermatitis (AD) has a marked negative impact on patient quality of life and can cause financial burden owing to a lack of effective treatments.

Dupilumab significantly improved signs and symptoms of AD with an acceptable safety profile in a 16‐week randomized, double‐blind, placebo‐controlled phase III study in children aged ≥ 6 to < 12 years with severe AD.

What does this study add?

This study extends information on the safety, efficacy and pharmacokinetic profile of dupilumab treatment for up to 52 weeks in children aged ≥ 6 to < 12 years with severe AD.

The results support the use of dupilumab as a continuous long‐term treatment for children aged ≥ 6 to < 12 years with severe AD.

Linked Comment: Sibbald. Br J Dermatol 2021; 184:792–793.

Long-term efficacy of certolizumab pegol for the treatment of plaque psoriasis: 3-year results from two randomized phase III trials (CIMPASI-1 and CIMPASI-2)

Background

Certolizumab pegol (CZP) is an Fc‐free, PEGylated anti‐tumour necrosis factor biologic.

Objectives

To report the 3‐year efficacy of CZP in plaque psoriasis, pooled from the CIMPASI‐1 (NCT02326298) and CIMPASI‐2 (NCT02326272) phase III trials.

Methods

Adults with moderate‐to‐severe psoriasis for ≥ 6 months were randomized 2 : 2 : 1 to CZP 200 mg, CZP 400 mg or placebo, every 2 weeks (Q2W) for up to 48 weeks. Patients entering the open‐label period (weeks 48–144) from double‐blinded CZP initially received CZP 200 mg Q2W. Patients not achieving ≥ 50% improvement in Psoriasis Area and Severity Index (PASI 50) at week 16 entered an open‐label CZP 400 mg Q2W escape arm (weeks 16–144). Dose adjustments based on PASI response were permitted during open‐label treatment. Outcomes included PASI 75, PASI 90 and Physician’s Global Assessment (PGA) 0/1 responder rates, based on a logistic regression model (missing data imputed using Markov Chain Monte Carlo methodology).

Results

In total, 186 patients were randomized to CZP 200 mg Q2W and 175 to CZP 400 mg Q2W. At week 48, PASI 75/90 was achieved by 72·7%/51·3% of patients randomized to CZP 200 mg and 84·4%/62·7% randomized to CZP 400 mg. Patients entering the open‐label period at week 48, from blinded treatment, received CZP 200 mg Q2W. At week 144, PASI 75/90 was achieved by 70·6%/48·7% patients randomized to CZP 200 mg and 72·9%/42·7% randomized to CZP 400 mg. At week 16, 72 placebo‐randomized patients entered the CZP 400 mg Q2W escape arm; 75.7%/58.5% achieved PASI 75/90 at week 144.

Conclusions

Both CZP 200 mg and 400 mg Q2W demonstrated sustained, durable efficacy, with numerically higher responses for some outcomes with 400 mg Q2W.

What is already known about this topic?

Certolizumab pegol is an Fc‐free, PEGylated, anti‐tumour necrosis factor biologic approved for adults with moderate‐to‐severe plaque psoriasis.

Efficacy data from the first 48 weeks of phase III trials have shown significant improvements in the signs and symptoms of psoriasis with certolizumab pegol dosed at either 400 mg or 200 mg every 2 weeks.

Numerically greater improvements were observed for patients treated with the higher dose.

What does this study add?

Plaque psoriasis is a chronic, systemic disease that requires long‐term management and sustained efficacy of therapies.

Three‐year efficacy data pooled from the CIMPASI‐1 and CIMPASI‐2 phase III trials demonstrate a sustained and durable response to certolizumab pegol dosed at either 400 mg or 200 mg every 2 weeks.

Additional long‐term clinical benefits may be obtained from the higher dose.

Linked Comment: Johnson et al. Br J Dermatol 2021; 184:588–589.

Tofacitinib in psoriatic arthritis patients: skin signs and symptoms and health-related quality of life from two randomized phase 3 studies

Background

Psoriatic arthritis (PsA) is a chronic, systemic immune‐mediated inflammatory musculoskeletal disease. The onset of dermatologic symptoms often precedes rheumatic manifestations. Tofacitinib is an oral Janus kinase inhibitor for the treatment of PsA that has been shown to improve dermatologic symptoms in patients with PsA.

Objectives

To investigate the efficacy of tofacitinib in improving dermatologic endpoints in adult patients with active PsA.

Methods

This analysis included data from two placebo‐controlled, double‐blind, phase 3 studies in patients with active PsA and an inadequate response (IR) to ≥1 conventional synthetic disease‐modifying antirheumatic drug (csDMARD) who were tumor necrosis factor inhibitor (TNFi)‐naïve (OPAL Broaden; NCT01877668) or an IR to ≥1 TNFi (OPAL Beyond; NCT01882439). Patients had active plaque psoriasis at screening and received a stable dose of one csDMARD during the study. Patients were randomized to tofacitinib 5 mg twice daily (BID), 10 mg BID, adalimumab 40 mg subcutaneous injection once every 2 weeks (OPAL Broaden only) or placebo (to Month 3). Dermatologic endpoints: Psoriasis Area and Severity Index (PASI) total score; PASI90 overall; PASI75 and PASI90 by baseline PASI severity; Physician’s Global Assessment of Psoriasis; Nail Psoriasis Severity Index; Dermatology Life Quality Index total and sub‐dimension scores; Itch Severity Item; and Patient’s Global Joint and Skin Assessment‐Visual Analog Scale‐Psoriasis question.

Results

In patients with active PsA, including those stratified by mild or moderate/severe dermatologic symptoms, greater improvements from baseline and percentage of responders were observed in tofacitinib‐treated patients vs. placebo for the majority of analyzed dermatologic endpoints at Months 1 and 3, and improvements were maintained to Month 12 in OPAL Broaden and Month 6 in OPAL Beyond. Similar effects were observed in adalimumab‐treated patients vs. placebo in OPAL Broaden across dermatologic endpoints.

Conclusions

Tofacitinib provides a treatment option for patients with active PsA, including the burdensome dermatologic symptoms of PsA.

AB0759 FOUR-YEAR EFFICACY AND SAFETY OF GUSELKUMAB IN PSORIASIS PATIENTS WITH AND WITHOUT PSORIATIC ARTHRITIS: A POOLED ANALYSIS FROM VOYAGE 1 AND VOYAGE 2

Background:

Guselkumab (GUS), a fully human monoclonal antibody, selectively binds and blocks interleukin-23. VOYAGE 1 and VOYAGE 2 are two ongoing Phase 3, randomized, double-blind, placebo (PBO)/active comparator-controlled clinical trials of GUS in patients (pts) with moderate-to-severe psoriasis (PsO).

Objectives:

This post-hoc analysis reports pooled results through 4 years among a subgroup of moderate-to-severe PsO pts with self-reported psoriatic arthritis (PsA) at baseline.

Methods:

1829 pts were randomized to GUS 100 mg at Weeks (Wks) 0, 4, and 12, then every 8 wks (q8wk); PBO at Wks 0, 4, and 12, GUS at Wks 16 and 20 then q8wk; or adalimumab (ADA) 80 mg at Wk 0, 40 mg at Wk 1, then 40 mg q2wk until Wk 47 (VOYAGE 1) or Wk 23 (VOYAGE 2). In VOYAGE 1, all pts received open-label GUS 100 mg q8wk during Wks 52-204. VOYAGE 2 incorporated a randomized withdrawal study design, followed by open-label GUS during Wks 76-204. Pooled subgroup analyses using the combined GUS group were conducted based on self-reported PsA status at baseline. Efficacy based on Investigator Global Assessment (IGA) score and Psoriasis Area and Severity Index (PASI) response was assessed using prespecified treatment failure rules (nonresponder status for all time points after discontinuing due to lack of efficacy, worsening of PsO, or use of a prohibited treatment).

Results:

For pooled VOYAGE 1 and VOYAGE 2 pts (N=1721), combined GUS and ADA to GUS response rates at Wks 100, 156, and 204 were: PASI 90 80.6%, 80.0%, and 80.4%; PASI 100 50.1%, 49.9%, and 52.2%; IGA 0/1 83.6%, 83.3%, and 81.7%; and IGA 0 54.3%, 52.9%, and 53.9, respectively. In the pooled subgroup analysis of pts with and without PsA, response rates were similar across the Wk 100, Wk 156, and Wk 204 evaluations (Table). Rates of adverse events through Wk 204 were comparable for pts with PsA vs those without PsA at baseline.

Conclusion:

Among GUS-treated pts with moderate-to-severe PsO with and without self-reported PsA at baseline, stable, durable, and high levels of skin responses, as well as comparable safety outcomes, through 4 years were observed.

Table.

Acknowledgments:

None

Disclosure of Interests:

Kristian Reich Grant/research support from: Janssen Research & Development, LLC, Jan Dutz Grant/research support from: Janssen Research & Development, LLC, Peter Foley Grant/research support from: Janssen Research & Development, LLC, Diamant Thaçi Grant/research support from: Janssen Research & Development, LLC, Ronald Vender Grant/research support from: Janssen Research & Development, LLC, Michael Song Employee of: Janssen Research & Development, LLC, Megan Miller Employee of: Janssen Research & Development, LLC, Yin You Employee of: Janssen Research & Development, LLC, Shu Li Employee of: Janssen Research & Development, LLC, Yaung-Kaung Shen Employee of: Janssen Research & Development, LLC, April Armstrong Grant/research support from: Janssen Research & Development, LLC

AB1289-HPR PERCEPTION OF THE VALUE OF DRUGS ON DIFFERENT MANIFESTATIONS OF PSORIATIC ARTHRITIS BASED ON A MULTI-STAGE EXPERT OPINION SURVEY

Background:

Patients with psoriatic arthritis (PsA) present with heterogeneous clinical phenotypes, which includes different clinical manifestations such as peripheral arthritis, axial disease, dactylitis, enthesitis, and skin and nail psoriasis. Many drugs for treatment of PsA are available for individualised treatment strategies but robust evidence is available for peripheral arthritis only as primary endpoint of RCTs.

Objectives:

To evaluate perception of German physicians on the value of current PsA treatments on different clinical PsA manifestations.

Methods:

In a face-to-face meeting, 8 German physicians (dermatology, rheumatology), specialised in PsA research/patient care, proposed initial scores for the effect size of current PsA drugs on different PsA manifestations based on knowledge of study data and personal experience in use of the drugs. The ability to achieve a consensus of the proposed efficacy scores was explored by applying an online survey among a cohort of PsA experienced physicians. Finally, a second online survey evaluated how a larger group of physicians personally estimate the drug effect sizes on different PsA manifestations.

Results:

Table 1 summarises the efficacy scores proposed by the initial expert group. In the first online survey 25 treating physicians were invited to participate, 14 (56%) of whom completed the survey. An agreement rate of over 65% of the participants was archived for 49 (68%) of the 72 proposed efficacy scores (Table 1). The consensus was especially high for the group of biological disease-modifying antirheumatic drugs (bDMARDs), except for etanercept and abatacept. However, the second survey (16 (39%) participants out of 41 invited physicians) revealed that the experience with the treatment using abatacept was low (4 / 16 (25%)) or non-existing (3 /16 (18.8%)) and several manifestations could not be estimated (Figure 1). Distribution of answers were broad for etanercept in general and for particular drug-manifestation combinations (e.g. effect of ustekinumab on axial disease).

Table 1.

Efficacy scores proposed by a PsA expert group and consensus achieved by an online survey among PsA treating physicians Efficacy scores for different drugs and manifestations range from 0 (no effect) to 5 (maximal effect). Green fields indicate, that at least 65% of the survey participants agreed on the proposed efficacy score.

Peripheral arthritisAxial diseaseEnthesitisDactylitisSkin diseaseNail diseaseMethotrexat2.50012.51.5Sulfasalazin100000Leflunomid2.500111Apremilast3132.533Etanercept4443.533.5Infliximab444444Adalimumab444444.5Golimumab444433Certolizumab pegol444444Ustekinumab3.52.54.534.54Secukinumab444454.5Abatacept3.50001.50Figure 1.

Results from an online survey among physicians querying their perception of efficacies of PsA drugs on different manifestations. Therapeutic effectiveness is estimated by the participants on a scale from 0 (no effect) to 5 (maximal effectiveness); NA = no answer. The size of the dots relates to the number of answers given. Red stars indicate the scores proposed by the initial expert group.

Conclusion:

Many treatments are available to be used in PsA. The usage of treatment classes seems to depend on experience level and mode of action. Higher agreement on efficacy in specific diseases manifestation was achieved in the class of biologics whereas the opinion on efficacy of csDMARDs in general is divergent. Strategies are needed to guide physicians with lower level of experience in the use of specific drugs to achieve an optimised patient care level using personalized treatment strategies.

Disclosure of Interests:

Timm Oberwahrenbrock Grant/research support from: BMS, Hannah Tian: None declared, Diamant Thaçi Grant/research support from: Janssen Research & Development, LLC, Klaus Krueger Consultant of: Celgene, Jürgen Wollenhaupt Consultant of: Celgene, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai

Klinik für Dermatologie, Allergologie und Venerologie der Universität zu Lübeck: Interaktion von Forschung und klinischer Versorgung

Die Ursprünge der Lübecker Universitäts-Hautklinik reichen in die 30er-Jahre des letzten Jahrhunderts zurück. Die Klinik hat in den letzten Jahrzehnten eine konsequente bauliche und inhaltliche Weiterentwicklung erfahren und verfügt heute über 85 Betten auf 2 Stationen und in einer Tagesklinik. Ein modernes Weiterbildungsprogramm, das auf einem Rotationsprinzip durch 5 verschiedene stationäre und ambulante Teams beruht, vermittelt alle wesentlichen Lerninhalte der Dermatologie. Die Erweiterung der Klinik in den letzten Jahren beruhte auf einer engen Interaktion von Grundlagenforschung und klinischer Tätigkeit, insbesondere auf dem Gebiet kutaner Autoimmunerkrankungen und entzündlicher Dermatosen. Die wissenschaftliche Entwicklung der Hautklinik profitierte seit 2007 insbesondere von der Förderung durch die Exzellenzinitiative des Bundes (Exzellenzcluster Inflammation at Interfaces). Daneben wurde durch die Deutsche Forschungsgemeinschaft (DFG) seit 2011 unter Federführung der Hautklinik ein Graduiertenkolleg Modulation of Autoimmunity gefördert, das zur Entwicklung des wissenschaftlichen Nachwuchses und zur Ausbildung zahlreicher naturwissenschaftlicher und medizinischer Doktoranden/Doktorandinnen1 beitrug. Seit 2015 besteht an der Klinik auch eine Klinische Forschungsgruppe der DFG zum Thema Pemphigoid Diseases – Molecular Pathways and their Therapeutic Potential. Im Jahr 2018 haben Mitarbeiter der Klinik wesentlich zur Einwerbung eines Clinician Scientist-Programms der DFG beigetragen, das die wissenschaftliche Ausbildung forschender Kliniker verbessern soll. In den letzten Jahren haben sich aus der Lübecker Hautklinik heraus 2 eigenständige Institute neu etabliert. Hierzu zählen das Institut für Entzündungsmedizin unter der Leitung von Prof. Diamant Thaçi, in dem klinische Studien zu entzündlichen Hauterkrankungen initiiert und koordiniert werden und die Versorgung von Patienten mit entzündlichen Dermatosen stattfindet. Daneben ist aus der Hautklinik heraus das Lübecker Institut für Experimentelle Dermatologie (LIED) entstanden, in dem derzeit 5 Professoren mit ihren jeweiligen Arbeitsgruppen zu unterschiedlichen Themen der Entzündung an der Haut forschen. Die interdisziplinären wissenschaftlichen Aktivitäten zur Entzündung an der Haut am Lübecker Campus werden seit 2015 in einem Center for Research on Inflammation of the Skin (CRIS) gebündelt. CRIS erhielt kürzlich die Zusage für ein eigenständiges Forschungsgebäude, das nach § 91 Grundgesetz durch Bund und Land finanziert wird und derzeit im Zentrum des Lübecker Campus entsteht. Der Ausbau der Forschungsstrukturen der Klinik ging mit der Einrichtung von Spezialambulanzen für verschiedene entzündliche Hauterkrankungen, aber auch für die Versorgung von Hautkrebs und chronischen Wunden einher. Die Klinik verfügt über ein zertifiziertes Hautkrebszentrum und ist Teil der Lübecker universitären Gefäß- und Krebszentren. Weitere wichtige Pfeiler der klinischen Versorgung sind zertifizierte diagnostische Einsendelabore für Dermato-Histopathologie und kutane Autoimmunerkrankungen.

A 24-week multicentre, randomized, open-label, parallel-group study comparing the efficacy and safety of ixekizumab vs. fumaric acid esters and methotrexate in patients with moderate-to-severe plaque psoriasis naive to systemic treatment

Background

Interleukin‐17 antagonists have received a first‐line label for moderate‐to‐severe plaque psoriasis.

Objectives

We conducted the first head‐to‐head trial between the two most commonly used first‐line therapies in Germany, fumaric acid esters (FAEs) and methotrexate, and the interleukin‐17A antagonist, ixekizumab.

Methods

Systemic‐naive patients were randomized in this parallel‐group, active‐comparator, open‐label, rater‐blinded trial (each group n = 54). The primary outcome was the proportion of patients achieving ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) at 24 weeks. Key secondary outcomes included 24‐week PASI 90 and 100, static Physician's Global Assessment (sPGA) score of 0 or 1, and Dermatology Life Quality Index (DLQI) score of 0 or 1. Safety events at week 24 were analysed using Fisher's exact test. Missing data were imputed using nonresponder imputation. The trial was registered at ClinicalTrials.gov (NCT02634801) and EudraCT (2015‐002649‐69).

Results

At week 24, more ixekizumab‐treated patients achieved PASI 75 [91% vs. 22% FAEs (P < 0·001) and 70% methotrexate (P = 0·014)], PASI 90 [80% vs. 9% FAEs (P < 0·001) and 39% methotrexate (P < 0·001)] and PASI 100 [41% vs. 4% FAEs (P < 0·001) and 13% methotrexate (P = 0·0041)], as well as sPGA (0,1) and DLQI (0,1).

Conclusions

Ixekizumab was superior in inducing PASI 75/90/100, sPGA (0,1) and DLQI (0,1) responses at week 24 compared with methotrexate and FAEs. Safety profiles for all treatments were consistent with prior studies.

What's already known about this topic?

Fumaric acid esters (FAEs) and methotrexate are two frequently used conventional systemic therapies for chronic plaque psoriasis.

A recent meta‐analysis of methotrexate showed a ≥ 75% reduction in Psoriasis Area and Severity Index (PASI 75) rate of 45·2% from primary end points at either 12 or 16 weeks.

Until recently, FAEs were licensed for psoriasis only in Germany, but were used in many other European countries as off‐label treatment of psoriasis. In 2017, the European Medicines Agency approved dimethyl fumarate, presumed to be the main active ingredient of FAEs, for the treatment of adult patients with moderate‐to‐severe chronic plaque psoriasis.

What does this study add?

This study is the first randomized, head‐to‐head trial comparing a biologic treatment with these therapies in a systemic‐treatment‐naive patient population.

This study shows the low tolerability of FAEs leading to a significant discontinuation rate, the better tolerability and moderate efficacy of methotrexate, and the good tolerability, fast onset of action and high efficacy of ixekizumab in an unbiased comparison.

Our findings reinforce the favourable risk–benefit profile of ixekizumab shown previously and provide further evidence of its efficacy at 24 weeks.

https://doi.org/10.1111/bjd.18905 available online

Dupilumab in adolescents with uncontrolled moderate-to-severe atopic dermatitis: results from a phase IIa open-label trial and subsequent phase III open-label extension

Background

Dupilumab (monoclonal antibody inhibiting IL‐4/IL‐13 signalling) is approved for use in adolescents aged ≥ 12 years with inadequately controlled moderate‐to‐severe atopic dermatitis (AD). Dupilumab significantly improved AD signs/symptoms in a 16‐week, randomised, placebo‐controlled phase III trial in adolescents (NCT03054428).

Objectives

To characterize the pharmacokinetics of dupilumab, and long‐term safety and efficacy in adolescents.

Methods

This was a global, multicentre, phase IIa, open‐label, ascending‐dose, sequential cohort study with a phase III open‐label extension (OLE) in adolescents with moderate‐to‐severe AD. In the phase IIa study, patients received one dupilumab dose (2 mg kg⁻¹ or 4 mg kg⁻¹) and 8 weeks of pharmacokinetic sampling. Thereafter, patients received the same dose weekly for 4 weeks, with 8‐week safety follow‐up. Patients then enrolled in the OLE, continuing 2 mg kg⁻¹ or 4 mg kg⁻¹ dupilumab weekly. Primary end points were dupilumab concentration–time profile and incidence of treatment‐emergent adverse events (TEAEs). Secondary outcomes included Eczema Area and Severity Index (EASI).

Results

Forty adolescents received dupilumab in the phase IIa study; 36 enrolled in the OLE. Dupilumab showed nonlinear, target‐mediated pharmacokinetics. Mean ± SD trough dupilumab concentrations in serum at week 48 (OLE) were 74 ± 19 mg L⁻¹ and 161 ± 60 mg L⁻¹ for 2 mg kg⁻¹ and 4 mg kg⁻¹, respectively. Dupilumab was well tolerated over 52 weeks; the most common TEAEs were nasopharyngitis (week 52: 41% [2 mg kg⁻¹], 47% [4 mg kg⁻¹]) and AD exacerbation (29%, 42%). After one dupilumab dose in the phase IIa study, EASI improved from baseline to week 2 [mean ± SD reduction −34% ± 20% (2 mg kg⁻¹) and −51% ± 29% (4 mg kg⁻¹)]. With continuing treatment, EASI scores improved further [week 52: −85% ± 12% (2 mg kg⁻¹) and −84% ± 20% (4 mg kg⁻¹)].

Conclusions

In adolescents with moderate‐to‐severe AD, dupilumab's pharmacokinetic profile was similar to that in adults. These 52‐week safety and efficacy data support long‐term use of dupilumab in this patient population.

What's already known about this topic?

Adolescents with moderate‐to‐severe atopic dermatitis (AD) have high unmet medical need, with significant disease burden and limited treatment options.

Dupilumab (monoclonal antibody against interleukin‐4 receptor α) is approved for the treatment of adolescents with moderate‐to‐severe AD who are inadequately responsive to standard of care (U.S.A.) or candidates for systemic therapy (European Union).

A 16‐week, randomized, placebo‐controlled phase III trial in adolescents demonstrated significant improvements in AD signs/symptoms with an acceptable safety profile.

What does this study add?

These studies demonstrate the long‐term safety and efficacy of dupilumab in adolescents with moderate‐to‐severe AD for up to 52 weeks of treatment, thus extending and reinforcing the findings from the 16‐week dupilumab phase III trial.

The data from these studies also support the use of dupilumab in combination with current standard of care (topical corticosteroids), which was not evaluated in the 16‐week phase III monotherapy trial.

Linked Comment: https://doi.org/10.1111/bjd.18627.

https://doi.org/10.1111/bjd.18661 available online

[The skin and rheumatism]

The skin is commonly affected in chronic inflammatory disorders and may act as a visual marker for internal or systemic inflammation. Frequent inflammatory skin diseases, like psoriasis and atopic dermatitis (AD), are associated with rheumatic and inflammatory bowel diseases. Metabolic, mental and cardiovascular comorbidity are frequent consequences of chronic inflammation. Further intersections between skin and joints are connective tissue diseases (collagenoses) and can be observed in complex diseases, e.g. systemic lupus erythematosus. Clinically, these diseases range from predominant cutaneous to severe systemic implication of several organs. Localized scleroderma should be clinically distinguished from systemic sclerosis and treated sufficiently to avoid long-term damage and disability. Thus, interdisciplinary disease management is of crucial importance.

Itch relief in patients with psoriasis: effectiveness of calcipotriol plus betamethasone dipropionate foam

BACKGROUND

Itch is common in psoriasis, adversely affecting health-related quality of life (HRQoL) and sleep.

OBJECTIVE

We evaluated the efficacy of topical fixed-dose combination calcipotriol 50 μg/g plus betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) on itch, itch-related sleep loss and HRQoL vs. foam vehicle.

METHODS

We pooled data from three Phase II/III trials (NCT01536886/NCT01866163/NCT02132936) of Cal/BD foam vs. foam vehicle in adults with mild-severe psoriasis. For itch-related analyses, patients with baseline itch visual analogue scale (VAS) >40 (range 0-100) were analysed. Outcomes included the following: itch VAS reduction >40, ≥70% improvement in itch (Itch70) or itch-related sleep loss, 75% improvement in modified Psoriasis Area and Severity Index (excluding head; mPASI75) and Dermatology Life Quality Index (DLQI) scores 0/1 through 4 weeks.

RESULTS

Of 837 patients, 800 had baseline itch VAS >0 (Cal/BD foam, n = 610; foam vehicle, n = 190); 484 had baseline itch VAS >40. There was no correlation between itch VAS score and mPASI at baseline (R²  = 0.021). In patients with baseline itch VAS >40, more patients achieved itch VAS reduction >40 in the active vs. vehicle group from Day 5 onwards (Day 5: 57.5% vs. 40.2% [P < 0.05]; Week 4: 83.0% vs. 45.8% [P < 0.001]). More Cal/BD-foam-treated patients achieved Itch70 at Day 3 (34.2% vs. 22.5%; P < 0.05) through to Week 4 (79.3% vs. 38.1%; P < 0.001). In patients with baseline itch VAS >40 and sleep loss >20, improvements in itch-related sleep loss occurred at Week 1 and continued through 4 weeks. Itch-related improvements occurred before improvements in mPASI75. There were significant differences in the proportion of Cal/BD-foam- vs. foam-vehicle-treated patients with baseline DLQI >10 (n = 172 vs. n = 50) achieving DLQI ≤1 (25.0% vs. 4.0%; P = 0.001) and DLQI 0 (17.4% vs. 2.0%; P = 0.006) at Week 4.

CONCLUSION

Compared with foam vehicle, Cal/BD foam offers more rapid and effective itch relief, with associated significant improvements in sleep and DLQI.

Sustained long-term efficacy and safety of adalimumab in paediatric patients with severe chronic plaque psoriasis from a randomized, double-blind, phase III study

BACKGROUND

Adalimumab (ADA) (Humira^® , AbbVie Inc., U.S.A.) is approved by the European Medicines Agency for children aged ≥ 4 years with severe plaque psoriasis.

OBJECTIVES

To evaluate the long-term efficacy and safety of ADA in children with severe plaque psoriasis.

METHODS

Results are presented from the 52-week long-term extension (LTE) of the randomized, double-blind, double-dummy, phase III trial, in children with severe plaque psoriasis (results from prior periods have been published). Patients aged ≥ 4 and < 18 years were randomized 1 : 1 : 1 to ADA 0·8 mg kg^-1 (40 mg maximum) or 0·4 mg kg^-1 (20 mg maximum) every other week or to methotrexate (MTX) 0·1-0·4 mg kg^-1 (25 mg maximum) weekly. The 16-week initial treatment (IT) period was followed by a 36-week withdrawal period and a 16-week retreatment period. Patients could enter the LTE at prespecified time points to receive ADA 0·8 mg kg^-1 (blinded or open label) or ADA 0·4 mg kg^-1 (blinded), or to remain off treatment. Efficacy is reported for patient groups according to doses received in the IT and LTE periods.

RESULTS

Of the 114 patients randomized in the IT period, 108 entered the LTE (n = 36 in each group); 93 received ADA 0·8 mg kg^-1 . Efficacy (≥ 75% improvement from baseline in Psoriasis Area and Severity Index) was maintained or improved from entry to the end of the LTE: MTX(IT)/ADA 0·8(LTE) 31-86% of patients; ADA 0·4(IT)/0·4 or 0·8(LTE) 28-47%; ADA 0·8(IT)/0·8(LTE) 50-72%. No serious infections occurred in the LTE.

CONCLUSIONS

After 52 weeks of long-term ADA treatment in children aged 4-18 years with severe plaque psoriasis, disease severity was reduced and maintained or further improved, as demonstrated by efficacy outcomes. No new safety risks were identified. What's already known about this topic? The results from the first three periods of this phase III trial in children aged 4-18 years with severe plaque psoriasis suggest that adalimumab is a safe and efficacious treatment option in this population. What does this study add? This is the first study to evaluate long-term treatment of adalimumab in children with severe psoriasis, and the first to evaluate switching from methotrexate to adalimumab in this population.

Long-term efficacy and safety of tildrakizumab for moderate-to-severe psoriasis: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2) through 148 weeks

Background

Tildrakizumab is a specific anti‐interleukin‐23p19 monoclonal antibody approved for the treatment of plaque psoriasis.

Objectives

To evaluate the long‐term efficacy and safety of tildrakizumab treatment for patients with moderate‐to‐severe psoriasis for up to 148 weeks.

Methods

Pooled analysis from two double‐blind, randomized controlled trials: reSURFACE 1 and reSURFACE 2. Efficacy was assessed for responders (≥ 75% improvement in Psoriasis Area and Severity Index; PASI 75) and partial responders (PASI 50–75) to tildrakizumab 100 mg and 200 mg at week 28 who were maintained on the same dose (administered every 12 weeks), and for partial responders or nonresponders (PASI < 50) to etanercept 50 mg at week 28 who, after a 4‐week washout, were switched to tildrakizumab 200 mg (administered at weeks 32 and 36, and every 12 weeks thereafter). Safety was assessed in the all‐patients‐as‐treated population. Three different methods of imputing missing data were used: nonresponder imputation (NRI), multiple imputation and observed cases. The Clinicaltrials.gov numbers are NCT01722331 (reSURFACE 1) and NCT01729754 (reSURFACE 2).

Results

At week 148 (NRI), 72·6%, 53·8% and 28·9% of tildrakizumab 100‐mg responders and 80·2%, 59·9% and 32·6% of tildrakizumab 200‐mg responders had PASI 75, 90 and 100 responses, respectively. For partial responders to tildrakizumab 100 mg and 200 mg, the proportions of patients achieving PASI 75, 90 and 100 responses were 32·5%, 25·0% and 10·0%; and 47·1%, 27·5% and 12·8%, respectively. For patients who were partial responders or nonresponders to etanercept, the proportions of patients achieving PASI 75, 90 and 100 responses were 66·9%, 43·8% and 14·9% at week 148. Rates of discontinuations due to adverse events [tildrakizumab 100 mg: 1·7 per 100 patient‐years (PYs); tildrakizumab 200 mg: 1·2 per 100 PYs] and exposure‐adjusted rates of serious adverse events (5·9 per 100 PYs; 5·5 per 100 PYs), severe infections (1·1 per 100 PYs; 1·1 per 100 PYs), malignancies (0·6 per 100 PYs; 0·4 per 100 PYs) and major adverse cardiovascular events (0·4 per 100 PYs; 0·5 per 100 PYs) were low.

Conclusions

Tildrakizumab was well tolerated and efficacy was well maintained in week 28 responders who continued tildrakizumab treatment through 3 years, or improved among etanercept partial responders or nonresponders who switched to tildrakizumab.

What's already known about this topic?

Tildrakizumab 100 mg and 200 mg are efficacious and well tolerated with short‐term use in the treatment of patients with moderate‐to‐severe plaque psoriasis.

What does this study add?

High levels of efficacy are maintained for up to 3 years of psoriasis treatment with tildrakizumab.

There is a favourable long‐term safety profile with both tildrakizumab 100 mg and 200 mg, with a low incidence of adverse events of special interest through 3 years.

https://doi.org/10.1111/bjd.18831 available online

https://www.bjdonline.com/article/

Combined culture and metagenomic analyses reveal significant shifts in the composition of the cutaneous microbiome in psoriasis

BACKGROUND

The treatment of psoriasis has been revolutionized by the development of biologic therapies. However, the pathogenesis of psoriasis, in particular the role of the cutaneous microbiome, remains incompletely understood. Moreover, skin microbiome studies have relied heavily on 16S rRNA sequencing data in the absence of bacterial culture.

OBJECTIVES

To characterize and compare the cutaneous microbiome in 20 healthy controls and 23 patients with psoriasis using metagenomic analyses and to determine changes in the microbiome during treatment.

METHODS

Swabs from lesional and nonlesional skin from patients with psoriasis, and from controls matched for site and skin microenvironment, were analysed using both 16S rRNA sequencing and traditional culture combined with mass spectrometry (MALDI-TOF) in a prospective study.

RESULTS

Psoriasis was associated with an increased abundance of Firmicutes and a corresponding reduction in Actinobacteria, most marked in lesional skin, and at least partially reversed during systemic treatment. Shifts in bacterial community composition in lesional sites were reflected in similar changes in culturable bacteria, although changes in the microbiota over repeated swabbing were detectable only with sequencing. The composition of the microbial communities varied by skin site and microenvironment. Prevotella and Staphylococcus were significantly associated with lesional skin, and Anaerococcus and Propionibacterium with nonlesional skin. There were no significant differences in the amount of bacteria cultured from the skin of healthy controls and patients with psoriasis.

CONCLUSIONS

Shifts in the cutaneous microbiome in psoriasis, particularly during treatment, may shed new light on the pathogenesis of the disease and may be clinically exploited to predict treatment response. What's already known about this topic? Alterations in the composition of the cutaneous microbiome have been described in psoriasis, although methodological differences in study design prevent direct comparison of results. To date, most cutaneous microbiome studies have focused on 16S rRNA sequencing data, including both living and dead bacteria. What does this study add? This prospective observational study confirms that changes in the composition of the cutaneous microbiome, detected by 16S rRNA sequencing, are consistent with those identified by bacterial culture and mass spectrometry. The changes in the microbiome during antipsoriasis therapy should be further investigated to determine whether these represent potential novel biomarkers of treatment response. What is the translational message? Characterization of cutaneous microbiota may ultimately move into the clinic to help facilitate treatment selection, not only by optimizing currently available treatments, but also by identifying new therapeutic targets.

Dupilumab provides important clinical benefits to patients with atopic dermatitis who do not achieve clear or almost clear skin according to the Investigator's Global Assessment: a pooled analysis of data from two phase III trials

BACKGROUND

In the U.S.A., an Investigator's Global Assessment (IGA) score of ≤ 1 (clear or almost clear skin) has been the standard measure in regulatory outcomes for registration clinical trials in atopic dermatitis (AD), including those supporting the recent approval of dupilumab.

OBJECTIVES

To evaluate the treatment effect of dupilumab in patients with IGA > 1 at the end of treatment, using other validated outcome measures for AD signs, symptoms and quality of life.

METHODS

LIBERTY AD SOLO 1 and 2 were two 16-week, randomized, double-blind trials enrolling adult patients with moderate-to-severe AD (IGA ≥ 3) inadequately controlled with topical treatment. We performed a post hoc analysis in patients receiving dupilumab 300 mg every 2 weeks (q2w) or placebo. Outcome measures in patients with IGA > 1 included Eczema Area and Severity Index (EASI), pruritus numerical rating scale (NRS), affected body surface area (BSA), Patient-Oriented Eczema Measure (POEM) and Dermatology Life Quality Index (DLQI). The trials were registered at ClinicalTrials.gov: NCT02277743 and NCT02277769.

RESULTS

At week 16, 278 of 449 dupilumab q2w-treated patients (median age 36·0 years) and 396 of 443 placebo-treated patients had IGA > 1. Among patients with IGA > 1 at week 16, dupilumab significantly improved several outcome measures compared with placebo: EASI (-48·9% vs. -11·3%, P < 0·001), pruritus NRS (-35·2% vs. -9·1%, P < 0·001), affected BSA (-23·1% vs. -4·5%, P < 0·001), POEM score ≥ 4-point improvement (57·4% vs. 21·0%, P < 0·001) and DLQI score ≥ 4-point improvement (59·3% vs. 24·4%, P < 0·001).

CONCLUSIONS

In patients with IGA > 1 at week 16, dupilumab induced statistically significant benefits in multiple validated outcome measures compared with placebo. The IGA ≤ 1 end point significantly underestimates clinically relevant dupilumab treatment effects.

Rapid onset of action of calcipotriol/betamethasone dipropionate cutaneous foam in psoriasis, even in patients with more severe disease

BACKGROUND

The effectiveness of topical therapies in psoriasis is dependent on, amongst other factors, patient adherence. Together with treatment effectiveness and reduction of symptoms, speed of onset and health-related quality of life (HRQoL) are important influencers of adherence.

METHODS

This pooled analysis of three Phase II/III trials evaluated the efficacy of topical fixed-dose combination calcipotriol 50 μg/g plus betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) vs. foam vehicle at early timepoints in mild-to-severe psoriasis using clinically meaningful modified Psoriasis Area and Severity Index (mPASI) and Dermatology Life Quality Index (DLQI) targets.

RESULTS

A greater proportion of Cal/BD-foam- vs. foam-vehicle-treated patients achieved absolute mPASI targets 0 (15.1% vs. 1.0%), ≤1 (41.4% vs. 5.2%), ≤3 (78.5% vs. 29.2%) and ≤5 (90.2% vs. 62.5%) at week 4 (P < 0.001; all targets). Significant differences between Cal/BD-foam- vs. foam-vehicle-treated patients were observed as early as week 1 in those achieving mPASI ≤1 (6.8% vs. 1.5%; P < 0.01), ≤3 (40.4% vs. 22.8%; P < 0.001) and ≤5 (69.7% vs. 50.8%; P < 0.001). In patients with more severe psoriasis (baseline mPASI >10), a greater proportion of Cal/BD-foam- vs. foam-vehicle-treated patients achieved mPASI ≤1 (20.2% vs. 5.9%; P < 0.05), ≤3 (49.2% vs. 8.8%; P < 0.001) and ≤5 (63.7% vs. 26.5%; P < 0.001) at week 4. In patients with severely impaired HRQoL (baseline DLQI >10), a greater proportion of Cal/BD-foam- vs. foam-vehicle-treated patients achieved target DLQI ≤1 or 0 (week 4: DLQI ≤1, 25.0% vs. 4%; P = 0.001; DLQI 0, 17.4% vs. 2.0%; P = 0.006).

CONCLUSION

We report rapid onset of action and greater efficacy with Cal/BD foam vs. foam vehicle, even in patients with more severe psoriasis, manageable with topical treatments. This may support physician management of patient expectations and improve patient adherence, translating into overall topical treatment effectiveness.