1
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van Riel CAM, Michielsens CAJ, van Muijen ME, van der Schoot LS, van den Reek JMPA, de Jong EMGJ. Dose reduction of biologics in patients with plaque psoriasis: a review. Front Pharmacol 2024; 15:1369805. [PMID: 38606178 PMCID: PMC11007084 DOI: 10.3389/fphar.2024.1369805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/04/2024] [Indexed: 04/13/2024] Open
Abstract
Dose reduction (DR) of first-generation biologics for plaque psoriasis (TNF-alpha inhibitors (i) and interleukin (IL)-12/23i) has been described in a previous scoping review. The literature on the DR of the newest generation of biologics (IL-17/23i) was scarce. The current review provides a literature update on the previous scoping review on the DR of all biologics, including the newest generation, with a focus on the uptake and implementation of DR in practice. The current literature search on DR revealed 14 new articles in addition to those in the previous review. Four of the newly found articles tested DR strategies, mostly focusing on first-generation biologics; only guselkumab (IL-23i) was included in one study. The other 10 studies showed data on regaining response after failure of DR, safety, cost-effectiveness, and uptake and implementation, as well as information about IL-17/23i. The eligibility criteria to start DR included both absolute and relative Psoriasis Area and Severity Index (PASI) scores (PASI ≤3/≤5/PASI 75-100) and/or Dermatology Life Quality Index (DLQI) ≤3/≤5, or BSA ≤1/≤2, or Physician Global Assessment (PGA) ≤1/0-2 during a period ranging from 12 weeks to ≥1 year. Most studies used PASI ≤5 and/or DLQI ≤5 or PGA ≤1 for ≥6 months. DR strategies were mostly performed by stepwise interval prolongation in two steps (to 67% of the standard dose, followed by 50%). Some studies of IL-17/23i reduced the dose to ±25%. The tested DR strategies on stepwise or fixed DR on TNF-αi and IL-12/23i (three studies), as well as one "on-demand" dosing study on IL-23i guselkumab, were successful. In the case of relapse of DR on TNF-αi and IL-12/23i, clinical effectiveness was regained by retreatment with the standard dose. All studies showed substantial cost savings with the biologic DR of TNF-αi and IL-12/23i. The identified barriers against the implementation of DR were mainly a lack of guidelines and scientific evidence on effectiveness and safety, and a lack of time and (technical) support. The identified facilitators were mainly clear guidelines, feasible protocols, adequate education of patients and physicians, and cost reduction. In conclusion, DR seems promising, but a research gap still exists in randomized, prospective studies testing DR strategies, especially of IL-17/23i, hampering the completion of guidelines on DR. Taking into account the identified barriers and facilitators most likely results in a more successful implementation of biologic DR in practice.
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Affiliation(s)
- C. A. M. van Riel
- Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, Gelderland, Netherlands
| | - C. A. J. Michielsens
- Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, Gelderland, Netherlands
| | - M. E. van Muijen
- Maastricht University Medical Centre, Maastricht, Limburg, Netherlands
- Department of Dermatology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands, Netherlands
| | - L. S. van der Schoot
- Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, Gelderland, Netherlands
| | - J. M. P. A. van den Reek
- Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, Gelderland, Netherlands
| | - E. M. G. J. de Jong
- Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, Gelderland, Netherlands
- Radboud University, Nijmegen, Gelderland, Netherlands
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2
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Thomas SE, van Reek JMPA, Bruins FM, Groenewoud HMM, de Jong EMGJ, Seyger MMB. Unveiling the impact of itch, pain, fatigue and disease severity in paediatric patients with psoriasis and the influence of methotrexate and biologics. J Eur Acad Dermatol Venereol 2024. [PMID: 38450775 DOI: 10.1111/jdv.19942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Affiliation(s)
- S E Thomas
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J M P A van Reek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - F M Bruins
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - H M M Groenewoud
- Department for Health Evidence, Radboud University, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Al-Gawahiri M, van den Reek JMPA, van Acht MR, Evers AWM, de Jong EMGJ, Seyger MMB. The lifestyle of psoriasis patients and their motivation to change. J Eur Acad Dermatol Venereol 2024. [PMID: 38400656 DOI: 10.1111/jdv.19923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Affiliation(s)
- M Al-Gawahiri
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - M R van Acht
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - A W M Evers
- Health, Medical, and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Medical Delta, Leiden University, Technical University of Delft, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
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Meeder EMG, Zwerink LGJM, Janzing JGE, de Jong EMGJ, van der Vleuten CJM. Psychiatric comorbidity in patients with vascular malformations and congenital overgrowth syndromes: A cohort study. J Eur Acad Dermatol Venereol 2023. [PMID: 38112304 DOI: 10.1111/jdv.19751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Affiliation(s)
- E M G Meeder
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L G J M Zwerink
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Expertise Center for Hemangiomas and Congenital Vascular Malformations Nijmegen (Hecovan), Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G E Janzing
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C J M van der Vleuten
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Expertise Center for Hemangiomas and Congenital Vascular Malformations Nijmegen (Hecovan), Radboud University Medical Center, Nijmegen, The Netherlands
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Ter Haar ELM, van den Reek JMPA, Ten Bruin EE, Bronkhorst EM, Borgonjen RJ, Kleinpenning MM, Kop EN, Visch MB, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Exclusion by age, cardiovascular comorbidity and malignancies are the main factors that impact generalizability of evidence from trials to the real-world situation in older adults with psoriasis. J Eur Acad Dermatol Venereol 2023; 37:e1471-e1474. [PMID: 37471529 DOI: 10.1111/jdv.19368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Affiliation(s)
- E L M Ter Haar
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - E E Ten Bruin
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - E M Bronkhorst
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R J Borgonjen
- Department of Dermatology, Gelderse Vallei Hospital and Padberg Clinic, Ede, The Netherlands
| | - M M Kleinpenning
- Department of Dermatology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - E N Kop
- Department of Dermatology, Bernhoven Hospital, Uden, The Netherlands
| | - M B Visch
- Department of Dermatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - S F K Lubeek
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
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van der Schoot LS, Janssen JJ, Bastiaens MT, de Boer-Brand A, Christiaansen-Smit C, Enomoto DNH, Hovingh R, Tupker RA, Seyger MMB, Verhoef LM, van den Reek JMPA, de Jong EMGJ. Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice. J DERMATOL TREAT 2023; 34:2186728. [PMID: 36867069 PMCID: PMC10013325 DOI: 10.1080/09546634.2023.2186728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Dose reduction (DR) of adalimumab, etanercept and ustekinumab has proven to be (cost-)effective in psoriasis patients with low disease activity. Further implementation is needed to establish application of DR for eligible patients. OBJECTIVES To evaluate the implementation of protocolized biologic DR in daily practice. METHODS A pilot implementation study was performed in 3 hospitals during 6 months. By combining education and protocol development, involved healthcare providers (HCPs) were directed toward the adoption of protocolized DR. DR of adalimumab, etanercept, and ustekinumab was achieved by stepwise injection interval prolongation. Implementation outcomes (fidelity, feasibility) were assessed. Factors for optimizing implementation were explored in interviews with HCPs. Uptake was measured in patients by chart review. RESULTS The implementation strategy was executed as planned. Implementation fidelity was less than 100% as not all provided tools were used across study sites. HCPs indicated the feasibility of implementing protocolized DR, although time investment was needed. Identified additional factors for successful implementation included support for patients, uptake of DR into guidelines, and supportive electronic health record systems. During the 6 months intervention period, 52 patients were eligible for DR of whom 26 (50%) started DR. The proposed DR protocol was followed in 22/26 patients (85%) on DR. CONCLUSION Additional staff for support, extra time during consultations, education on DR for HCPs and patients, and effective tools such as a feasible protocol can lead to more patients on biologic DR.
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Affiliation(s)
- L S van der Schoot
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J Janssen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M T Bastiaens
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - A de Boer-Brand
- Department of Dermatology, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - C Christiaansen-Smit
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - D N H Enomoto
- Department of Dermatology, Dermatologisch Centrum Isala, Zwolle, The Netherlands
| | - R Hovingh
- Department of Dermatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - R A Tupker
- Department of Dermatology, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
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van der Schoot LS, Verhoef LM, van Ee I, van Oort FPAH, Pieterse AH, Seyger MMB, de Jong EMGJ, van den Reek JMPA. Patients' perspectives towards biologic dose reduction in psoriasis: a qualitative study. Arch Dermatol Res 2023; 315:1735-1745. [PMID: 36813868 PMCID: PMC10338615 DOI: 10.1007/s00403-023-02566-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 11/22/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023]
Abstract
Dose reduction of biologics for psoriasis could contribute to more efficient use of these expensive medicines. Evidence on opinions of patients with psoriasis regarding dose reduction is sparse. The objective of this study was therefore to explore patients' perspectives towards dose reduction of biologics for psoriasis. A qualitative study was conducted, comprising semi-structured interviews with 15 patients with psoriasis with different characteristics and treatment experiences. Interviews were analyzed by inductive thematic analysis. Perceived benefits of biologic dose reduction according to patients were minimizing medication use, lowering risks of adverse effects and lowering societal healthcare costs. Patients reported to have experienced a large impact of their psoriasis, and expressed concerns about loss of disease control due to dose reduction. Fast access to flare treatment and adequate monitoring of disease activity were among reported preconditions. According to patients, they should have confidence in dose reduction effects and should be willing to change their effective treatment. Moreover, addressing information needs and involvement in decision-making were deemed important among patients. In conclusion, addressing patients' concerns, fulfilling information needs, providing the possibility of resuming standard dose, and involving patients in decision-making are important according to patients with psoriasis when considering biologic dose reduction.
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Affiliation(s)
- L S van der Schoot
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - I van Ee
- Psoriasispatiënten Nederland, Dutch National Psoriasis Patient Association, Nijkerk, The Netherlands
| | - F P A H van Oort
- Psoriasispatiënten Nederland, Dutch National Psoriasis Patient Association, Nijkerk, The Netherlands
| | - A H Pieterse
- Psoriasispatiënten Nederland, Dutch National Psoriasis Patient Association, Nijkerk, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University, Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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8
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van der Schoot LS, Baerveldt EM, van Enst WA, Menting SP, Seyger MMB, Wanders SL, van Ee I, Pieterse AH, van den Reek JMPA, de Jong EMGJ. National consensus on biologic dose reduction in psoriasis: a modified eDelphi procedure. J DERMATOL TREAT 2022; 34:2154570. [PMID: 36472386 DOI: 10.1080/09546634.2022.2154570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dose reduction of biologics for psoriasis is applied in daily practice, although guidelines are lacking. Striving for clear criteria is important, as it leads to a consistent application of dose reduction. OBJECTIVE To achieve consensus on criteria for biologic dose reduction in psoriasis patients with stable and low disease activity. METHODS An online Delphi procedure (eDelphi) was conducted. Dutch dermatologists were invited to participate in a maximum of 3 voting rounds. Proposed statements were selected based on literature review and included criteria for the application of dose reduction and dosing schedules. Biologic dose reduction was defined as 'application of injection interval prolongation'. Proposed statements were rated using a 9-point Likert scale; consensus was reached when ≥70% of all voters rated 'agree' (7-9) and <15% rated 'disagree' (1-3). RESULTS A total of 27 dermatologists participated and reached a consensus on 15 recommendations over 2 voting rounds. Agreed statements included criteria for dose reduction eligibility, criteria for dose reduction (dis)continuation, and dosing schedules for adalimumab, etanercept, and ustekinumab. Based on the eDelphi outcomes, an algorithm fit for implementation in current practice was developed. CONCLUSIONS Recommendations of this national consensus process can guide clinicians, and consequently their patients, toward consistent application of biologic dose reduction.
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Affiliation(s)
- L S van der Schoot
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - E M Baerveldt
- Department of Dermatology, IJsselland Ziekenhuis, Capelle aan den IJssel, the Netherlands
| | - W A van Enst
- Dutch Association for Dermatology and Venereology, Utrecht, the Netherlands
| | - S P Menting
- Department of Dermatology, OLVG, Amsterdam, the Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S L Wanders
- Dutch Association for Dermatology and Venereology, Utrecht, the Netherlands
| | - I van Ee
- Psoriasispatiënten Nederland, Dutch National Psoriasis Patient Association, Nijkerk, the Netherlands
| | - A H Pieterse
- Psoriasispatiënten Nederland, Dutch National Psoriasis Patient Association, Nijkerk, the Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboud University, Nijmegen, the Netherlands
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9
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van Winden MEC, Klösters FM, Hamaker M, Olde Rikkert MG, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Optimizing shared decision-making in older adults with basal cell carcinoma: experiences from a specialized outpatient clinic. Br J Dermatol 2021; 186:589-591. [PMID: 34698375 PMCID: PMC9306910 DOI: 10.1111/bjd.20833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
Balancing the risk for under- and overtreatment in older adults with basal cell carcinoma (BCC) frequently proves challenging.1,2 As BCCs are slowly growing tumors and initially asymptomatic, patients with limited life expectancy (LLE) might frequently be overtreated,2 leading to unnecessary and avoidable treatment burden, while little or no improvement in quality of life might be achieved. To improve patient-centered care for older BCC patients, it was hypothesized that a more holistic approach, with specific attention for patient-related factors and treatment goals, leads to different BCC management choices, better aligning with patient preferences, and resulting in less overtreatment.
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Affiliation(s)
- M E C van Winden
- Department of Dermatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - F M Klösters
- Department of Dermatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - M Hamaker
- Department of Geriatrics, Diakonessenhuis, Zeist, the Netherlands
| | - M G Olde Rikkert
- Department of Geriatrics, Radboud University Medical Center Nijmegen, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - S F K Lubeek
- Department of Dermatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Schaap MJ, Cardozo NJ, Patel A, de Jong EMGJ, van Ginneken B, Seyger MMB. Image-based automated Psoriasis Area Severity Index scoring by Convolutional Neural Networks. J Eur Acad Dermatol Venereol 2021; 36:68-75. [PMID: 34653265 PMCID: PMC9298301 DOI: 10.1111/jdv.17711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022]
Abstract
Background The Psoriasis Area and Severity Index (PASI) score is commonly used in clinical practice and research to monitor disease severity and determine treatment efficacy. Automating the PASI score with deep learning algorithms, like Convolutional Neural Networks (CNNs), could enable objective and efficient PASI scoring. Objectives To assess the performance of image‐based automated PASI scoring in anatomical regions by CNNs and compare the performance of CNNs to image‐based scoring by physicians. Methods Imaging series were matched to PASI subscores determined in real life by the treating physician. CNNs were trained using standardized imaging series of 576 trunk, 614 arm and 541 leg regions. CNNs were separately trained for each PASI subscore (erythema, desquamation, induration and area) in each anatomical region (trunk, arms and legs). The head region was excluded for anonymity. Additionally, PASI‐trained physicians retrospectively determined image‐based subscores on the test set images of the trunk. Agreement with the real‐life scores was determined with the intraclass correlation coefficient (ICC) and compared between the CNNs and physicians. Results Intraclass correlation coefficients between the CNN and real‐life scores of the trunk region were 0.616, 0.580, 0.580 and 0.793 for erythema, desquamation, induration and area, respectively, with similar results for the arms and legs region. PASI‐trained physicians (N = 5) were in moderate–good agreement (ICCs 0.706–0.793) with each other for image‐based PASI scoring of the trunk region. ICCs between the CNN and real‐life scores were slightly higher for erythema (0.616 vs. 0.558), induration (0.580 vs. 0.573) and area scoring (0.793 vs. 0.694) than image‐based scoring by physicians. Physicians slightly outperformed the CNN on desquamation scoring (0.580 vs. 0.589). Conclusions Convolutional Neural Networks have the potential to automatically and objectively perform image‐based PASI scoring at an anatomical region level. For erythema, desquamation and induration scoring, CNNs performed similar to physicians, while for area scoring CNNs outperformed physicians on image‐based PASI scoring.
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Affiliation(s)
- M J Schaap
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N J Cardozo
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Patel
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B van Ginneken
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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van Muijen ME, van der Schoot LS, van den Reek JMPA, de Jong EMGJ. Attitudes and behaviour regarding dose reduction of biologics for psoriasis: a survey among dermatologists worldwide. Arch Dermatol Res 2021; 314:687-695. [PMID: 34467442 PMCID: PMC9307528 DOI: 10.1007/s00403-021-02273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 01/23/2023]
Abstract
Dose reduction (DR) of biologics, where possible, seems promising for more efficient use of expensive biologics. For implementation of DR strategies, it is essential to get insight in factors that influence implementation. The objective of this study was to evaluate the attitudes and behaviour regarding dose reduction of biologic therapies for psoriasis among psoriasis expert dermatologists worldwide. A 27-question e-survey was sent through the International Psoriasis Council (IPC) to its 114 dermatologist councilors worldwide. The survey assessed demographics, general and DR prescription behaviour, and motivations for and barriers against application of DR. Of 57 respondents, 53 respondents who prescribed biologics were included for analysis. Thirty-seven (69.8%) applied DR (i.e., ‘DR dermatologists’), and 16 (30.2%) did not (i.e., ‘Non-DR dermatologists’). DR strategies varied among respondents. Regarding criteria for starting DR, differences were reported in required treatment duration, and interpretation and duration of stable low disease activity. In addition, the prolongation of intervals between injections varied between respondents. For most ‘DR dermatologists’ (n = 32/37, 86.5%), cost savings were one of the main reasons to apply DR. Fifteen out of 16 ‘Non-DR dermatologists’ (94%) did not apply DR due to lack of scientific evidence. In conclusion, DR of biologics for psoriasis is part of clinical practice in psoriasis experts globally. Barriers for applying DR included lack of evidence or guidelines, and uncertainty on DR effects and risks. Although growing evidence shows DR feasibility, future studies are needed to accumulate and broaden evidence, along with development of (inter)national guidelines on DR strategies.
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Affiliation(s)
- M E van Muijen
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
- Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - L S van der Schoot
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands.
- Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands.
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
- Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
- Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
- Radboud University, Nijmegen, The Netherlands
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12
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Abstract
Introduction Biologics serve as a cornerstone in psoriasis treatment, with low disease activity or sometimes even clinical remission as a realistic treatment outcome. So far, it is unclear whether biologics should be tapered when this target is achieved. Dose tapering could offer potential benefits by decreasing side effects, the burden of repetitive injections and costs of biological therapy. However, clinical guidelines on dose tapering of biologicals in psoriasis patients are lacking. This scoping review was conducted to provide an overview of the current literature on dose tapering and offer guidance for clinicians in daily clinical practice. Methods Dose tapering is defined as the administration of a lower dose per administration, or the prolongation of the regular dose interval, after initial treatment according to the standard dosing. Four electronic databases (PubMed, EMBASE, Cochrane, and Web of Science) were systematically searched for literature on tapering of biologics in adult patients with psoriasis from 1 January 2000. Results We included 19 original articles on biologic tapering in psoriasis patients: four randomized controlled trials and 15 observational studies. Tapering eligibility criteria, tapering strategies, tapering outcomes, and recapture of response after relapse were assessed. Furthermore, the available evidence on possible predictors for successful tapering, and the effect of tapering on safety, quality of life and costs is summarized. The definition of low disease activity as a measure for tapering eligibility varied widely. Beside tapering criteria, tapering strategies were also heterogeneous. Of note, quality-of-life measurements were barely integrated in the evaluation of tapering outcomes. Literature on regaining response after relapse due to tapering was limited, but restored remission has been described. The included studies did not proclaim a significant effect of tapering on the occurrence of (severe) adverse events. Even though cost savings have been reported, no proper cost-effectiveness analysis has been conducted yet. Conclusion Biologic tapering seems to be effective and safe in psoriasis patients with stable low disease activity or clinical remission. Available data on biologic dose tapering in patients with psoriasis are promising, but more research is warranted to fill the current gaps in knowledge. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-020-01448-z. Biologics are effective in treating psoriasis amongst other diseases, such as rheumatoid arthritis and Crohn’s disease. However, biologics are costly, and can cause side effects, such as an increased risk of infection. In patients with rheumatoid arthritis, it is not uncommon to lower the dose of these biologics (also called “dose tapering”), once stable low disease activity, or even remission, is reached. However, in psoriasis patients, dose tapering of biologics is not common practice. In this “scoping review,” we provide an overview of the available literature on dose tapering of biologics in adult patients with plaque psoriasis in order to address the current gaps in literature. We found 19 studies that addressed dose tapering. These studies used different criteria to determine which patients were eligible for tapering, which led to various interpretations of tapering success. This made it difficult for us to draw general conclusions on which tapering criteria and strategies should be further investigated. Dose tapering seems to be effective and safe in patients with a stable low disease activity, although more (high-quality) research is needed. Future studies should focus on generating more data on long-term safety, finding predictors for successful tapering, calculating the cost-effectiveness of dose tapering, and evaluating dose tapering in the newest generation of biologics.
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Affiliation(s)
- C A J Michielsens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Mailbox 9101, 6500 HB, Nijmegen, The Netherlands. .,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands. .,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.
| | - M E van Muijen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Mailbox 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - J M P A van den Reek
- Radboud University Medical Center, Radboud Institute for Health Sciences, Mailbox 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Radboud University Medical Center, Radboud Institute for Health Sciences, Mailbox 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
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13
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Atalay S, van den Reek JMPA, Groenewoud JMM, van de Kerkhof PCM, Kievit W, de Jong EMGJ. Two-year follow-up of a dose reduction strategy trial of biologics adalimumab, etanercept, and ustekinumab in psoriasis patients in daily practice. J DERMATOL TREAT 2021; 33:1591-1597. [PMID: 33356686 DOI: 10.1080/09546634.2020.1869147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/OBJECTIVES Tightly-controlled dose reduction was possible during 1 year in psoriasis patients on adalimumab, etanercept or ustekinumab with low disease activity (CONDOR trial). Extended observation is needed to ensure long-term effectiveness and safety of the strategy. With prolonged follow-up, we investigated the clinical effects and safety of the strategy, the proportion of patients with successful dose reduction, and assessed if patients with a disease flare regained remission. METHODS Two-year follow up of a subgroup of patients previously included in a randomized pragmatic study comparing usual care (UC) with stepwise dose reduction (DR). Effectiveness (Psoriasis Area and Severity Index, PASI), Dermatology Life Quality Index (DLQI), adverse events, proportion of patients with successful DR and proportion of persistent disease flares were analyzed. RESULTS DR leads temporarily to a slightly increased PASI groupwise, but on the long-term patients regained low PASI. DLQI scores remained stable during follow-up. No serious adverse events due to DR were reported. Forty-one percent of patients remained on a low dose up to 2 years. The number of persistent flares was low in DR and UC. CONCLUSIONS The proposed dose reduction strategy is effective for a significant part of patients and remains safe up to 2 years of follow-up.
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Affiliation(s)
- S Atalay
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M M Groenewoud
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W Kievit
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
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14
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van Winden MEC, Ter Haar ELM, Groenewoud JMM, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Quality of life, treatment goals, preferences and satisfaction in older adults with psoriasis: a patient survey comparing age groups. Br J Dermatol 2020; 184:759-762. [PMID: 33152111 PMCID: PMC8246713 DOI: 10.1111/bjd.19665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Affiliation(s)
- M E C van Winden
- Department of Dermatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - E L M Ter Haar
- Department of Dermatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - J M M Groenewoud
- Department for Health Evidence, Radboud University, Nijmegen, the Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - S F K Lubeek
- Department of Dermatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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15
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van Winden MEC, Garcovich S, Peris K, Colloca G, de Jong EMGJ, Hamaker ME, van de Kerkhof PCM, Lubeek SFK. Frailty screening in dermato-oncology practice: a modified Delphi study and a systematic review of the literature. J Eur Acad Dermatol Venereol 2020; 35:95-104. [PMID: 32403174 PMCID: PMC7818261 DOI: 10.1111/jdv.16607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/28/2020] [Indexed: 12/21/2022]
Abstract
Background Appropriate management and prevention of both under‐ and overtreatment in older skin cancer patients can be challenging. It could be helpful to incorporate frailty screening in dermato‐oncology care, since frailty is associated with adverse health outcomes. Objectives This study aimed to identify and prioritize the requirements a frailty screening tool (FST) should fulfil in dermato‐oncology practice and to select the best existing FST(s) for this purpose. Methods A modified two‐round Delphi procedure was performed among 50 Italian and Dutch specialists and patients to review and prioritize a list of potential FST requirements, using a 5‐point Likert scale. Consensus was defined as a mean score of ≥4.0. A systematic literature search was performed to identify existing multidomain FSTs, which were then assessed on the requirements resulting from the modified Delphi procedure. Results Consensus was achieved on evaluation of comorbidities (4.3 ± 0.7), polypharmacy (4.0 ± 0.9) and cognition (4.1 ± 0.8). The FST should have appropriate measurement properties (4.0 ± 1.0), be quickly executed (4.2 ± 0.7), clinically relevant (4.3 ± 0.7), and both easily understandable (4.1 ± 1.2) and interpretable (4.3 ± 0.7). Of the 26 identified FSTs, four evaluated the content‐related domains: the Geriatric‐8 (G8), the modified Geriatric‐8 (mG8), the Groningen Frailty Indicator (GFI) and the Senior Adult Oncology Program 2 (SAOP2) screening tool. Of these, the G8 was the most extensively studied FST, with the best psychometric properties and execution within 5 min. Conclusions The G8 appears the most suitable FST for assessing frailty in older adults with skin cancer, although clinical studies assessing its use in a dermato‐oncology population are needed to further assess whether or not frailty in this particular patient group is associated with relevant outcomes (e.g. complications and mortality), as seen in previous studies in other medical fields.
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Affiliation(s)
- M E C van Winden
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Garcovich
- Institute of Dermatology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - K Peris
- Institute of Dermatology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G Colloca
- Department of Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M E Hamaker
- Department of Geriatrics, Diakonessenhuis, Zeist, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S F K Lubeek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
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16
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Bruins FM, Bronckers IMGJ, Cai R, Groenewoud JMM, Krol M, de Jong EMGJ, Seyger MMB. Treatment persistence in paediatric and adolescent patients with psoriasis followed into young adulthood. From topical to systemic treatment: a prospective, longitudinal, observational cohort study of 448 patients. Br J Dermatol 2020; 184:464-472. [PMID: 32510578 PMCID: PMC7984075 DOI: 10.1111/bjd.19301] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2020] [Indexed: 12/22/2022]
Abstract
Background Although solely topical treatment often suffices, patients with psoriasis may require more intensive treatment (phototherapy and/or systemic treatments) to control their disease. However, in paediatric, adolescent and young adult patients, little is known about persistence of topical treatment and time until switch to systemic treatment. Objectives To determine the median time from psoriasis onset until (i) discontinuation of solely topical agents and (ii) switch to systemic treatment, and to identify patient characteristics associated with switching to systemic treatments. Methods Data were extracted from the Child‐CAPTURE registry, a prospective, observational cohort of patients with paediatric‐onset psoriasis followed into young adulthood from 2008 to 2018. Data prior to inclusion in the registry were collected retrospectively. Median times were determined through Kaplan–Meier survival analyses. Cox regression analysis was used to identify patient characteristics associated with switch to systemic treatment. Results Of 448 patients, 62·3% stayed on solely topical treatment until data lock; 14·3% switched from topicals to phototherapy, but not to systemic treatment; and 23·4% switched to systemic treatment. The median time from psoriasis onset until discontinuation of solely topical treatment was 7·3 years, and until switch to systemics was 10·8 years. Higher Psoriasis Area and Severity Index and (Children’s) Dermatology Life Quality Index > 5 were independently associated with switching to systemic treatment. Conclusions In a population of paediatric and adolescent patients with mild‐to‐severe psoriasis, one‐third needed more intensive treatment than solely topical therapy to control their disease. We consider the median time until switching to systemics to be long. What is already known about this topic? Psoriasis in the majority of paediatric and adolescent patients can be adequately managed with solely topical treatment. However, some patients require a switch to more intensive treatment in order to control their disease. Little is known about persistence of topical treatment and time until switch to systemic treatment.
What does this study add? In 448 paediatric patients with mild‐to‐severe psoriasis, 62·3% persisted on solely topical treatment, 14·3% switched to phototherapy, but not to systemics, and 23·4% switched to systemic treatment at data lock (total median follow‐up 4·2 years, interquartile range 1·8–7·5). The median time from psoriasis onset until discontinuation of solely topical treatment was 7·3 years, and until switch to systemic treatment 10·8 years. Higher Psoriasis Area and Severity Index and (Children’s) Dermatology Life Quality Index > 5 at switch were independent characteristics associated with switching to systemic treatment.
Linked Comment: Salman. Br J Dermatol 2021; 184:387–388. Plain language summary available online
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Affiliation(s)
- F M Bruins
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - I M G J Bronckers
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Cai
- Real-World Evidence Solutions, IQVIA, Amsterdam, the Netherlands
| | - J M M Groenewoud
- Department for Health Evidence, Radboud University, Nijmegen, the Netherlands
| | - M Krol
- Real-World Evidence Solutions, IQVIA, Amsterdam, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
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17
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van der Kraaij GE, Balak DMW, Busard CI, van Cranenburgh OD, Chung Y, Driessen RJB, de Groot M, de Jong EMGJ, Kemperman PMJH, de Kort WJA, Karsch SA, Lamberts A, Lecluse LLA, van Lümig PPM, Menting SP, Prens EP, van den Reek JMPA, Seyger MMB, Thio HB, Veldkamp WR, Wakkee M, Nast A, Jacobs A, Rosumeck S, Spuls Chair PI. Highlights of the updated Dutch evidence- and consensus-based guideline on psoriasis 2017. Br J Dermatol 2019; 180:31-42. [PMID: 30604536 PMCID: PMC6849803 DOI: 10.1111/bjd.17198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2018] [Indexed: 12/31/2022]
Abstract
Linked Comment: https://doi.org/10.1111/bjd.17390.
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Affiliation(s)
- G E van der Kraaij
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Dutch Society of Dermatology and Venereology, Utrecht, the Netherlands
| | - D M W Balak
- University Medical Centre Utrecht, Utrecht, the Netherlands
| | - C I Busard
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O D van Cranenburgh
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Dutch Skin Foundation, Nieuwegein, the Netherlands
| | - Y Chung
- Dutch Society of Dermatology and Venereology, Utrecht, the Netherlands
| | - R J B Driessen
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M de Groot
- Antonius Hospital, Sneek/Emmeloord, the Netherlands
| | - E M G J de Jong
- Radboud University Medical Centre, Nijmegen, the Netherlands.,Radboud University Nijmegen, the Netherlands
| | - P M J H Kemperman
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Waterlandziekenhuis, Purmerend, the Netherlands
| | | | - S A Karsch
- Dutch Society of Dermatology and Venereology, Utrecht, the Netherlands
| | - A Lamberts
- Dutch Society of Dermatology and Venereology, Utrecht, the Netherlands.,University Medical Center Groningen, Groningen, the Netherlands
| | - L L A Lecluse
- Bergman Clinics and U-clinic, Amsterdam, the Netherlands
| | - P P M van Lümig
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S P Menting
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - E P Prens
- Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - M M B Seyger
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | - H B Thio
- Erasmus Medical Centre, Rotterdam, the Netherlands
| | - W R Veldkamp
- Dutch Society of Dermatology and Venereology, Utrecht, the Netherlands.,Radboud University Nijmegen, the Netherlands
| | - M Wakkee
- Erasmus Medical Centre, Rotterdam, the Netherlands
| | - A Nast
- Department of Dermatology, Venereology und Allergy, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - A Jacobs
- Department of Dermatology, Venereology und Allergy, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S Rosumeck
- Department of Dermatology, Venereology und Allergy, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - P I Spuls Chair
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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18
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Bronckers IMGJ, Maatkamp M, Kievit W, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. The association of scalp psoriasis with overall psoriasis severity and koebnerization in children: cross-sectional findings from the Dutch Child-CAPTURE registry. Br J Dermatol 2019; 181:1099-1101. [PMID: 31127952 DOI: 10.1111/bjd.18168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- I M G J Bronckers
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Maatkamp
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W Kievit
- Department for Health Evidence, Radboud University, Nijmegen, the Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands.,Faculty of Medical Sciences, Radboud University, Nijmegen, the Netherlands
| | - M M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
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19
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van der Schoot LS, van den Reek JMPA, Groenewoud JMM, Otero ME, Njoo MD, Ossenkoppele PM, Mommers JM, Koetsier MIA, Berends MAM, Arnold WP, Peters B, Andriessen MPM, Den Hengst CW, Kuijpers ALA, de Jong EMGJ. Female patients are less satisfied with biological treatment for psoriasis and experience more side-effects than male patients: results from the prospective BioCAPTURE registry. J Eur Acad Dermatol Venereol 2019; 33:1913-1920. [PMID: 31177583 DOI: 10.1111/jdv.15733] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/17/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Female sex has been reported as a predictor for treatment discontinuation with biological therapies for psoriasis, although reasons remain unclear. It can be hypothesized that lower satisfaction with biological treatment in women might add to the lower drug survival rates. OBJECTIVES To identify possible differences in satisfaction with biological treatment between female and male patients using the Treatment Satisfaction Questionnaire for Medication (TSQM). METHODS Data of psoriasis patients treated with biologics were obtained from the prospective, multicentre, daily-practice BioCAPTURE registry. Longitudinal TSQM data were analysed by linear mixed models. Relevant patient characteristics were incorporated as possible confounding factors. Post hoc analysis of adverse events was performed in order to investigate differences between sexes. RESULTS We included 315 patients with 396 corresponding treatment episodes (137 adalimumab, 90 etanercept, 137 ustekinumab, 24 secukinumab and 8 infliximab). Almost forty per cent of the patients were female. Women had significantly lower baseline PASI scores (P = 0.01). Longitudinal analyses demonstrated lower TSQM scores for 'side-effects' (P = 0.05) and 'global satisfaction' (P = 0.01) in female patients compared with male patients over 1 year of treatment. Women reported more relevant adverse events in the context of biologic treatment compared to men (rate ratio 1.79; P < 0.001), with more fungal (rate ratio 2.20; P = 0.001) and herpes simplex infections (rate ratio 3.25; P = 0.005). CONCLUSIONS This study provides a prospective, longitudinal analysis of treatment satisfaction with biologics in female and male patients with psoriasis. Women were slightly less satisfied with treatment regarding side-effects and global satisfaction. Differences in treatment satisfaction and side-effects might add to the fact that women discontinue biological treatments more often.
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Affiliation(s)
- L S van der Schoot
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M M Groenewoud
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M E Otero
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M D Njoo
- Department of Dermatology, Ziekenhuisgroep Twente, Almelo/Hengelo, the Netherlands
| | - P M Ossenkoppele
- Department of Dermatology, Ziekenhuisgroep Twente, Almelo/Hengelo, the Netherlands
| | - J M Mommers
- Department of Dermatology, St Anna Ziekenhuis, Geldrop, the Netherlands
| | - M I A Koetsier
- Department of Dermatology, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - M A M Berends
- Department of Dermatology, Slingeland Ziekenhuis, Doetinchem, the Netherlands
| | - W P Arnold
- Department of Dermatology, Ziekenhuis Gelderse Vallei, Ede, the Netherlands
| | - B Peters
- Department of Dermatology, Ziekenhuis Rijnstate, Arnhem, the Netherlands
| | - M P M Andriessen
- Department of Dermatology, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - C W Den Hengst
- Department of Dermatology, St Antonius Ziekenhuis, Woerden, the Netherlands
| | - A L A Kuijpers
- Department of Dermatology, Máxima Medisch Centrum, Eindhoven, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands.,Radboud University, Nijmegen, the Netherlands
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20
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van Beugen S, Ferwerda M, van Middendorp H, Smit JV, Zeeuwen-Franssen MEJ, Kroft EBM, de Jong EMGJ, van de Kerkhof PCM, Kievit W, Evers AWM. Economic evaluation of a tailored therapist-guided internet-based cognitive behavioural treatment for patients with psoriasis: a randomized controlled trial. Br J Dermatol 2019; 181:614-616. [PMID: 30822378 DOI: 10.1111/bjd.17848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S van Beugen
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Ferwerda
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H van Middendorp
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J V Smit
- Department of Dermatology, Rijnstate Hospital, Velp, the Netherlands
| | | | - E B M Kroft
- Department of Dermatology, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands.,Radboud University, Nijmegen, the Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A W M Evers
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
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21
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van Vugt LJ, van den Reek JMPA, Coenen MJH, de Jong EMGJ. A systematic review of pharmacogenetic studies on the response to biologics in patients with psoriasis. Br J Dermatol 2017. [PMID: 28646581 DOI: 10.1111/bjd.15753] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biologics are indicated for treating moderate-to-severe psoriasis. As the number of biologics registered for the treatment of psoriasis increases, so does the need for biomarkers to guide personalized therapeutic decisions. Genetic variants might serve as predictors for treatment response, a field of research known as pharmacogenetics. OBJECTIVES To assess which genetic variants are associated with response to biologics in patients with psoriasis according to current literature. METHODS A systematic search was performed in Embase, MEDLINE, the Cochrane Library and Web of Science. In total, 26 papers were included in this systematic review; 24 original studies and two meta-analyses. Quality was assessed using a predesigned form and risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS The majority of studies reported a candidate gene approach, focusing on polymorphisms in genes related to the therapeutic target or to psoriasis susceptibility. Studied populations were small and results were divergent, especially for studies investigating tumour necrosis factor inhibitors. The evidence for the role of HLA-Cw6 in ustekinumab efficacy shows minimal heterogeneity, with a higher response rate among patients who were positive for HLA-Cw6 reported across three of five studies. CONCLUSIONS Pharmacogenetic studies in psoriasis have generated divergent results. Replication of findings in larger cohorts is required. Large-scale hypothesis-free searches for genetic biomarkers are needed to uncover the complete genetic background of outcomes for treatment with biologics.
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Affiliation(s)
- L J van Vugt
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences (RIHS), Nijmegen, the Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences (RIHS), Nijmegen, the Netherlands
| | - M J H Coenen
- Radboud Institute for Health Sciences (RIHS), Nijmegen, the Netherlands.,Department of Human Genetics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences (RIHS), Nijmegen, the Netherlands.,Radboud University, Nijmegen, the Netherlands
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22
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van den Reek JMPA, Menting SP, Janssen WWL, Dhaliwal R, Heijboer AC, van Herwaarden AE, Sweep FCGJ, de Jong LM, Tjwa ET, Otero ME, Spuls PI, de Jong EMGJ. Procollagen-3 N-terminal peptide measurements for the detection of liver fibrosis in methotrexate-treated patients with psoriasis: daily practice use and clinical implications. Br J Dermatol 2017; 177:1454-1457. [PMID: 28112796 DOI: 10.1111/bjd.15313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- J M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S P Menting
- Department of Dermatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - W W L Janssen
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Dhaliwal
- Department of Allergology, University Medical Center, Groningen, the Netherlands
| | - A C Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, Amsterdam, the Netherlands
| | - A E van Herwaarden
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - F C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - L M de Jong
- Department of Dermatology, Ziekenhuis Gelderse Vallei, Ede, the Netherlands
| | - E T Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M E Otero
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P I Spuls
- Department of Dermatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,Radboud University, Nijmegen, the Netherlands
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23
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de Vries ACQ, Thio HB, de Kort WJA, Opmeer BC, van der Stok HM, de Jong EMGJ, Horvath B, Busschbach JJV, Nijsten TEC, Spuls PI. A prospective randomized controlled trial comparing infliximab and etanercept in patients with moderate-to-severe chronic plaque-type psoriasis: the Psoriasis Infliximab vs. Etanercept Comparison Evaluation (PIECE) study. Br J Dermatol 2017; 176:624-633. [PMID: 27416891 DOI: 10.1111/bjd.14867] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are currently no independent data available comparing infliximab and etanercept for the treatment of psoriasis. OBJECTIVES To compare these biologics without funding from pharmaceutical companies. METHODS Overall, 50 patients were randomized to etanercept (n = 23) 50 mg subcutaneously twice weekly or infliximab (n = 25) 5 mg kg-1 intravenously at week 0, 2, 6, 14 and 22. After 24 weeks, 19 patients stopped and 22 continued treatment and were followed up to week 48. The primary outcome was ≥ 75% improvement of Psoriasis Area and Severity Index (PASI 75) at week 24. The secondary outcomes included PASI 75 at week 6 (onset of action) and week 12, Investigator's Global Assessment (IGA), Patient Global Assessment, impact on quality of life (Skindex-17 and SF-36), Treatment Satisfaction Questionnaire of Medication, duration of remission, maintenance treatment and safety. RESULTS At week 24, PASI 75 was achieved in 72% (infliximab) vs. 35% (etanercept) (P = 0·01). The onset of action was achieved in 52% (infliximab) and 4% (etanercept). At week 12, 76% (infliximab) and 22% (etanercept) achieved PASI 75 (P < 0·001). At week 24, IGA 'clear or almost clear' was observed in 76% (infliximab) and 30% (etanercept) (P = 0·01). Skindex-17 symptom score was significantly better for infliximab. Maintenance treatment achieved PASI 75 for 67% (n = 6) infliximab vs. 50% (n = 5) etanercept, at week 48 (P = 0·65). Mild adverse events were reported in 76% (infliximab) vs. 66% (etanercept). CONCLUSIONS Infliximab showed a rapid and significant higher level of efficacy until week 24 compared with etanercept. Long-term data showed no significant differences between both groups at week 48. Safety parameters were comparable.
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Affiliation(s)
- A C Q de Vries
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - H B Thio
- Department of Dermatology, Erasmus Medical Center, 3015 CA, Rotterdam, the Netherlands
| | - W J A de Kort
- Department of Dermatology, Amphia Hospital, Molengracht 21, 4818 CK, Breda, the Netherlands
| | - B C Opmeer
- Clinical Research Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - H M van der Stok
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, UMC St Radboud, René Descartesdreef 1, 6525 GL, Nijmegen, the Netherlands
| | - B Horvath
- Department of Dermatology, UMC Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - J J V Busschbach
- Medical Psychology and Psychotherapy Section, Erasmus Medical Center, 3015 CA, Rotterdam, the Netherlands
| | - T E C Nijsten
- Department of Dermatology, Erasmus Medical Center, 3015 CA, Rotterdam, the Netherlands
| | - Ph I Spuls
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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24
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van Geel MJ, van de Kerkhof PCM, Oostveen AM, de Jong EMGJ, Seyger MMB. Fumaric acid esters in recalcitrant pediatric psoriasis: A prospective, daily clinical practice case series. J DERMATOL TREAT 2015; 27:214-20. [PMID: 26452994 DOI: 10.3109/09546634.2015.1088131] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Evidence on fumaric acid esters (FAE) in the treatment of pediatric psoriasis is scarce. OBJECTIVE Describe the effectiveness, influence on the quality of life (QoL) and safety of FAE in children with recalcitrant psoriasis in daily clinical practice. METHODS A prospective case series. RESULTS Fourteen patients with recalcitrant plaque-type psoriasis were described (mean age 13.7, range 8-17 years). Mean treatment duration was 48.6 weeks (range 12-124). Maximum daily dose varied between 180 and 1200 mg with a mean of 564 mg per day. Mean Psoriasis Area and Severity Index (PASI) (±SEM) at baseline was 10.5 (1.0) compared to 8.6 (1.1), 6.2 (1.6) and 4.9 (1.5) at week 12, 24 and 36, respectively. An improvement in PASI was observed in nine patients (64.3%). Mean CDLQI (±SEM) at week 0, 12, 24 and 36 was 8.9 (1.4), 6.8 (1.2), 3.7 (1.4) and 3.1 (2.0), respectively. Most common adverse events (AEs) were gastrointestinal complaints (n = 13, 92.9%) and flushes (n = 10, 71.4%). Lymphocytopenia (n = 5, 45.5%) and eosinophilia (n = 4, 36.4%) were frequently observed laboratory abnormalities. AEs were usually mild and transient. One serious adverse event, unrelated to FAE, was reported. CONCLUSIONS FAE showed improvement of disease severity and QoL in the majority of children. Side-effects occurred frequently, but were usually mild and transient. FAE may be an alternative systemic treatment option for pediatric psoriasis, provided that also the long-term safety data are closely monitored, in particular lymphocytopenia.
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Affiliation(s)
- M J van Geel
- a Department of Dermatology , Radboud university medical center , Nijmegen , The Netherlands
| | - P C M van de Kerkhof
- a Department of Dermatology , Radboud university medical center , Nijmegen , The Netherlands
| | - A M Oostveen
- a Department of Dermatology , Radboud university medical center , Nijmegen , The Netherlands
| | - E M G J de Jong
- a Department of Dermatology , Radboud university medical center , Nijmegen , The Netherlands
| | - M M B Seyger
- a Department of Dermatology , Radboud university medical center , Nijmegen , The Netherlands
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25
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Menting SP, van den Reek JMPA, Baerveldt EM, de Jong EMGJ, Prens EP, Lecluse LLA, Wolbink GJ, Van der Kleij D, Spuls PI, Rispens T. The correlation of clinical efficacy, serum trough levels and antidrug antibodies in ustekinumab-treated patients with psoriasis in a clinical-practice setting. Br J Dermatol 2015; 173:855-7. [PMID: 25865153 DOI: 10.1111/bjd.13834] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S P Menting
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands.
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - E M Baerveldt
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - E P Prens
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L L A Lecluse
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
| | - G J Wolbink
- Department of Immunopathology, Sanquin Research, Amsterdam, the Netherlands
| | - D Van der Kleij
- Department of Immunopathology, Sanquin Research, Amsterdam, the Netherlands.,Biologicals Laboratory, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - Ph I Spuls
- Department of Dermatology, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
| | - T Rispens
- Department of Immunopathology, Sanquin Research, Amsterdam, the Netherlands
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26
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Geel MJV, Oostveen AM, Hoppenreijs EPAH, Hendriks JCM, Kerkhof PCMVD, de Jong EMGJ, Seyger MMB. Methotrexate in pediatric plaque-type psoriasis: Long-term daily clinical practice results from the Child-CAPTURE registry. J DERMATOL TREAT 2015; 26:406-12. [DOI: 10.3109/09546634.2014.996515] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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van den Reek JMPA, van Lüumig PPM, Otero ME, Zweegers J, van de Kerkhof PCM, Ossenkoppele PM, Njoo MD, Mommers JM, Koetsier MIA, Arnold WP, Sybrandy-Fleuren BAM, Kuijpers ALA, Andriessen MPM, Seyger MMB, Kievit W, de Jong EMGJ. Satisfaction of treatment with biologics is high in psoriasis: results from the Bio-CAPTURE network. Br J Dermatol 2015; 170:1158-65. [PMID: 24484403 DOI: 10.1111/bjd.12862] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the effectiveness of biologics for psoriasis has been measured extensively with objective outcome measures, studies based on subjective, patient-reported outcome measures remain scarce. OBJECTIVES To investigate satisfaction with medication, as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM) for biologics in daily practice psoriasis care in the first 6 months of treatment; and to identify possible differences in satisfaction with medication between patients experienced (biologics-experienced) and inexperienced (biologics-inexperienced) in the use of biologics. METHODS TSQM baseline measurements were compared using measurements taken after 6 months, using the Wilcoxon signed-rank test for paired comparisons. Intention-to-treat with last observation carried forward (ITT with LOCF) and as-treated analyses were performed. The difference between biologics-experienced and biologics-inexperienced patients for TSQM was analysed using ITT with LOCF. At 6 months, outcomes for biologics-experienced and biologics-inexperienced patients were compared using the Mann-Whitney U-test. RESULTS One hundred and six patients were eligible for analysis, and treated with etanercept (n = 34), adalimumab (n = 49) or ustekinumab (n = 23). Fifty-four per cent of patients were biologics-inexperienced. A statistically significant improvement was seen in all domains of the TSQM ('effectiveness', 'side-effects', 'convenience' and 'global satisfaction') by comparison of months 3 or 6 with baseline (all P ≤ 0·02). After 6 months, biologics-inexperienced patients scored better on the 'global satisfaction' domain than biologics-experienced patients (P < 0·01). CONCLUSIONS We provide a prospective, longitudinal analysis of TSQM for biologics in daily practice psoriasis care. High satisfaction rates were achieved. The 'effectiveness' and 'convenience' domains showed the most room for improvement.
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Affiliation(s)
- J M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
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28
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van den Reek JMPA, van Lümig PPM, Driessen RJB, van de Kerkhof PCM, Seyger MMB, Kievit W, de Jong EMGJ. Determinants of drug survival for etanercept in a long-term daily practice cohort of patients with psoriasis. Br J Dermatol 2014; 170:415-24. [PMID: 24117023 DOI: 10.1111/bjd.12648] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Long-term data of etanercept drug survival in patients with psoriasis in daily practice are scarce. OBJECTIVES The primary objective was to describe drug survival for etanercept in a long-term daily practice cohort of patients with psoriasis. The secondary objective was to identify determinants of drug survival for etanercept in general and separately for discontinuation due to adverse events or ineffectiveness of therapy. METHODS Data were extracted from a prospective daily practice cohort of patients treated with biologics for psoriasis. Drug survival was analysed by Kaplan-Meier survival curves and split for two reasons for discontinuation: adverse events and ineffectiveness. Determinants of drug survival were analysed using univariate Cox regression analysis and multivariate Cox regression analysis with backward selection. RESULTS We included 193 patients (512 patient-years treated) with a maximum treatment duration of 7·5 years. The overall drug survival rates were 77%, 41% and 30% after 1, 4 and 7·5 years, respectively. The mean survival duration was 3·8 years (95% confidence interval 3·4-4·3). Reasons for discontinuation were ineffectiveness (33·7%), adverse events (11·9%), both ineffectiveness and adverse events (4·7%) or other reasons (e.g. pregnancy planned) (5·7%). Determinants related to longer general drug survival were male sex [hazard ratio (HR) 0·55], prior anti-tumour necrosis factor (TNF)-α use (HR 0·57) and lower etanercept dose (HR 0·65). Younger age (HR 0·83), lower body mass index (HR 0·63) and lower etanercept dose (HR 0·71) were related to a decreased risk of discontinuation due to side-effects. A lower mean weekly dose of etanercept (HR 0·63) was related to a decreased risk of discontinuation due to ineffectiveness of therapy. CONCLUSIONS We present the longest analysis of drug survival for etanercept in psoriasis to date. Determinants of longer overall etanercept drug survival were male sex, prior anti-TNF therapy and lower etanercept dose. The determinants of longer drug survival depended on the reason for discontinuation of etanercept.
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Affiliation(s)
- J M P A van den Reek
- Department of Dermatology, Radboud University Nijmegen Medical Centre, René Descartesdreef 1, 6525 GL, Nijmegen, the Netherlands
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29
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Oostveen AM, Beulens CA, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. The effectiveness and safety of short-contact dithranol therapy in paediatric psoriasis: a prospective comparison of regular day care and day care with telemedicine. Br J Dermatol 2014; 170:454-7. [PMID: 24024678 DOI: 10.1111/bjd.12621] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence on the effectiveness and safety of short-contact dithranol therapy in paediatric psoriasis is sparse and based only on retrospective data. The best results are achieved in a time-consuming day-care setting. OBJECTIVES To study prospectively the effectiveness and safety of short-contact dithranol therapy in paediatric psoriasis. In addition, the effectiveness, safety, duration of treatment and number of visits between regular day care and day care with telemedicine were compared. METHODS Data were collected from the prospective observational Child-CAPTURE registry of children with psoriasis. Effectiveness was measured as the mean percentage improvement in Psoriasis Area and Severity Index (PASI). Safety was assessed by recording adverse events. The number of visits and duration of treatment were reported. RESULTS For all patients a mean percentage reduction in PASI score of -69·3% was found, with no significant differences between regular day care and day care with telemedicine. The only adverse event reported was irritation of the skin. Neither the frequency of irritation during treatment nor the mean duration of treatment significantly differed between the two groups. Patients with telemedicine had significantly fewer visits. CONCLUSIONS This first prospective observational study demonstrates that short-contact dithranol therapy in paediatric psoriasis is effective and safe. Regular day care and day care with telemedicine are equally effective. Telemedicine can be of additional value as it is less time consuming. We hope it will therefore make dithranol treatment appropriate for a larger number of children with psoriasis.
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Affiliation(s)
- A M Oostveen
- Department of Dermatology, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
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30
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Otero ME, van Geel MJ, Hendriks JCM, van de Kerkhof PCM, Seyger MMB, de Jong EMGJ. A pilot study on the Psoriasis Area and Severity Index (PASI) for small areas: Presentation and implications of the Low PASI score. J DERMATOL TREAT 2014; 26:314-7. [DOI: 10.3109/09546634.2014.972316] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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31
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Reich K, Zschocke I, Bachelez H, de Jong EMGJ, Gisondi P, Puig L, Warren RB, Mrowietz U. Efficacy of a fixed combination of calcipotriol/betamethasone dipropionate topical gel in adult patients with mild to moderate psoriasis: blinded interim analysis of a phase IV, multicenter, randomized, controlled, prospective study. J Eur Acad Dermatol Venereol 2014; 29:1156-63. [PMID: 25346093 DOI: 10.1111/jdv.12774] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Psoriasis is a common, chronic, inflammatory skin disease with the majority of individuals having limited disease, treated with topical medication. However, special attributes of topical treatments like galenic/cosmetic properties or an inconvenient treatment schedule may result in low preference for topical treatments. Hence, there is strong medical need for a topical medication, which is highly efficacious, easy-to-use and preferred by both physicians and patients. OBJECTIVE Blinded interim analysis with the purpose to assess efficacy of (both from the physician's and patient's perspective) and the patients' preference with a highly efficacious and easy-to-use fixed combination of calcipotriol/betamethasone dipropionate topical gel after 8 weeks of once daily treatment in a large patient population. METHODS In this phase IV, international, multicentre, randomized, controlled, prospective, parallel group study, adult patients with active, mild to moderate psoriasis despite previous topical psoriasis treatment, i.e. unsuccessful in the 8 weeks preceding study participation, are followed over 64 weeks. During the first 8 weeks the patients apply their medication once a day followed by a 56-weeks maintenance period according to SmPC. Blinded interim analysis of all patients included demographics, Physician's Global Assessment, the novel Patient's self Global Assessment (PsGA) and Patient Preference Questionnaire (PPQ). RESULTS 1795 patients were analysed. At week 8, 36.5% of the physicians rated the patients' psoriasis as clear/almost clear. Similarly, based on the patients' self-assessment, 34.2% had a clear/almost clear score of PsGA in week 8. Analysis of the PPQ showed that the vast majority of the patients judged their 8-week treatment to be preferable compared with their previous treatments. CONCLUSION Results of this blinded interim analysis indicate that the fixed combination of calcipotriol/betamethasone dipropionate gel is highly efficacious and preferred by the majority of analysed patients.
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Affiliation(s)
- K Reich
- Dermatologikum Hamburg, Hamburg, Germany
| | | | - H Bachelez
- Sorbonne Paris Cité Université Paris-Diderot, Department of Dermatology, AP-HP Hôpital Saint-Louis, Paris, France
| | - E M G J de Jong
- Radboud university medical centre, Nijmegen, The Netherlands
| | - P Gisondi
- University of Verona Dermatology and Venerology Section, Verona, Italy
| | - L Puig
- Department of Dermatology Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - R B Warren
- The Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - U Mrowietz
- Psoriasis Zentrum Abteilung Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
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van den Reek JMPA, Zweegers J, Kievit W, Otero ME, van Lümig PPM, Driessen RJB, Ossenkoppele PM, Njoo MD, Mommers JM, Koetsier MIA, Arnold WP, Sybrandy-Fleuren BAM, Kuijpers ALA, Andriessen MPM, van de Kerkhof PCM, Seyger MMB, de Jong EMGJ. 'Happy' drug survival of adalimumab, etanercept and ustekinumab in psoriasis in daily practice care: results from the BioCAPTURE network. Br J Dermatol 2014; 171:1189-96. [PMID: 24807471 DOI: 10.1111/bjd.13087] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Drug survival is a marker for treatment success. To date, no analyses relating dermatological quality-of-life measures to drug survival have been published. OBJECTIVES (i) To describe 1-year drug survival for adalimumab, etanercept and ustekinumab in a daily practice psoriasis cohort, and (ii) to introduce the concept of 'happy' drug survival, defined as Dermatology Life Quality Index (DLQI) ≤ 5 combined with being 'on drug' at a specific time point. METHODS Data were extracted from a prospective registry. Drug survival was analysed using Kaplan-Meier estimates. 'Happy' drug survival was calculated, with data split into 'happy' (DLQI ≤ 5) vs. 'unhappy' (DLQI > 5) at baseline and months 3, 6, 9 and 12. RESULTS 249 treatment episodes were included (101 adalimumab, 82 etanercept, 66 ustekinumab). The 1-year drug survival rates for ustekinumab, adalimumab and etanercept were 85%, 74% and 68%, respectively. Ustekinumab showed a better confounder-corrected drug survival vs. etanercept [hazard ratio (HR) 3·8, P = 0·02] and a trend towards better survival vs. adalimumab (HR 2·3, P = 0·1). At baseline, the majority (n = 115, 73%) was considered 'unhappy' and a minority 'happy' (n = 42, 27%) (ratio 'happy':'unhappy' was 1 : 2.7). The percentage of treatment episodes with 'happy' on-drug patients increased to 79% after 1 year. CONCLUSIONS Ustekinumab showed a better overall drug survival than etanercept, and a trend towards a better overall drug survival than adalimumab. After 1 year, patients reported to be 'happy' in 79% of episodes and 'unhappy' in 21%. We introduced the new concept of 'happy' drug survival because the proportion of on-drug patients with good quality of life is an important indicator for treatment success.
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Affiliation(s)
- J M P A van den Reek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
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van Lümig PPM, Menting SP, van den Reek JMPA, Spuls PI, van Riel PLCM, van de Kerkhof PCM, Fransen J, Kievit W, de Jong EMGJ. An increased risk of non-melanoma skin cancer during TNF-inhibitor treatment in psoriasis patients compared to rheumatoid arthritis patients probably relates to disease-related factors. J Eur Acad Dermatol Venereol 2014; 29:752-60. [PMID: 25229823 DOI: 10.1111/jdv.12675] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 03/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Concerns exist about a risk of non-melanoma skin cancer (NMSC) in psoriasis patients and rheumatoid arthritis (RA) patients treated with TNF-inhibitors. However, current data also show that in some psoriasis patients, NMSC is diagnosed relatively short after the start of TNF-inhibitors, which suggests that these NMSC can be explained by previous therapies instead of by TNF-inhibitor therapy. OBJECTIVE To investigate whether there was a difference in time until first NMSC and the rate of NMSC between psoriasis and RA patients on TNF-inhibitors. METHODS Time until first NMSC and the rate of NMSC were compared between psoriasis and RA patients from the same region treated with TNF-inhibitors and followed up for at least one year in prospective cohort studies, by using Cox regression and Poisson regression. Both analyses were corrected for confounders (age, gender, disease duration, prior NMSC, duration of anti-TNF and other systemic therapies). RESULTS The NMSC risk was significantly higher in the psoriasis group [fully adjusted HR 6.0 (1.6-22.4 95%CI)] with a shorter time until first NMSC in psoriasis compared to RA. By Poisson regression, psoriasis patients had a 5.5 (2.2-13.4 95%CI) higher rate of NMSC. CONCLUSION The time until first NMSC was significantly shorter and the rate of NMSC was significantly higher in psoriasis compared with RA. This indicates that disease-related factors like phototherapy may be important contributing factors to NMSC diagnosed in psoriasis patients treated with TNF-inhibitors.
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Affiliation(s)
- P P M van Lümig
- Department of Dermatology, Radboud university medical center, Nijmegen, The Netherlands
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Zweegers J, de Jong EMGJ, Nijsten TEC, de Bes J, te Booij M, Borgonjen RJ, van Cranenburgh OD, van Deutekom H, van Everdingen JJE, de Groot M, Van Hees CLM, Hulshuizen H, Koek MBG, de Korte WJA, de Korte J, Lecluse LLA, Pasch MC, Poblete-Gutiérrez PA, Prens EP, Seyger MMB, Thio HB, Torcque LA, de Vries ACQ, van de Kerkhof PCM, Spuls PI. Summary of the Dutch S3-guidelines on the treatment of psoriasis 2011. Dutch Society of Dermatology and Venereology. Dermatol Online J 2014; 20:doj_21769. [PMID: 24656281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/17/2014] [Indexed: 06/03/2023] Open
Abstract
This document provides a summary of the Dutch S3-guidelines on the treatment of psoriasis. These guidelines were finalized in December 2011 and contain unique chapters on the treatment of psoriasis of the face and flexures, childhood psoriasis as well as the patient's perspective on treatment. They also cover the topical treatment of psoriasis, photo(chemo)therapy, conventional systemic therapy and biological therapy.
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Affiliation(s)
- J Zweegers
- Dutch Society of Dermatology and Venereology.
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Bergboer JGM, Oostveen AM, de Jager MEA, den Heijer M, Joosten I, van de Kerkhof PCM, Zeeuwen PLJM, de Jong EMGJ, Schalkwijk J, Seyger MMB. Paediatric-onset psoriasis is associated with ERAP1 and IL23R loci, LCE3C_LCE3B deletion and HLA-C*06. Br J Dermatol 2013; 167:922-5. [PMID: 22512642 DOI: 10.1111/j.1365-2133.2012.10992.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent genome-wide association studies have identified several genetic risk factors for psoriasis, but data on their association with age at onset are lacking. OBJECTIVES To compare the association between known risk alleles and psoriasis in well-defined cohorts with paediatric- and adult-onset psoriasis. METHODS Based on previous studies we selected seven genes and loci associated with psoriasis. Patients with paediatric-onset (< 18 years) and adult-onset psoriasis (≥ 18 years) and controls were genotyped. Genotype frequencies were compared between controls (n = 450) and all cases (n = 217), and between controls and cases stratified for confirmed age at onset (paediatric onset n = 80, adult onset n = 85). RESULTS Paediatric-onset psoriasis showed a significant association with single nucleotide polymorphisms in the ERAP1 (P = 0.042) and IL23R loci (P = 0.042), LCE3C_LCE3B-del (P = 0.003) and HLA-C*06 (P = 1.72 × 10(-19)) when compared with the control group. A significant association of these four genes was also demonstrated when all psoriasis cases were compared with controls. In adult-onset psoriasis a significant association was found for HLA-C*06 (P = 5.11 × 10(-6)) and for LCE3C_LCE3B-del (P = 0.042). No associations were found for the IFIH1, IL12B and TRAF3IP2 loci. CONCLUSIONS Notwithstanding the small cohort sizes, we demonstrated an association with established and recently discovered genetic risk factors in paediatric-onset psoriasis including genes involved in epidermal barrier function and adaptive immunity. Our data suggest that heritable factors may play a more important role in paediatric-onset psoriasis than in adult-onset psoriasis.
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Affiliation(s)
- J G M Bergboer
- Department of Dermatology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
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Mrowietz U, de Jong EMGJ, Kragballe K, Langley R, Nast A, Puig L, Reich K, Schmitt J, Warren RB. A consensus report on appropriate treatment optimization and transitioning in the management of moderate-to-severe plaque psoriasis. J Eur Acad Dermatol Venereol 2013; 28:438-53. [PMID: 23437792 DOI: 10.1111/jdv.12118] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 01/21/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is limited information on systemic and biological treatment optimization and transitioning in routine clinical practice. OBJECTIVE To provide practical guidance on treatment optimization and transitioning for moderate-to-severe plaque psoriasis. METHODS Dermatologists from 33 countries contributed to the Transitioning Therapies programme. Fourteen questions were identified. Answers were drafted based on systematic literature reviews (7/14 questions) and expert opinion (7/14 questions). Using a modified Delphi procedure, dermatologists from 30 countries voted on their level of agreement with each draft answer (scale: 1-9, strong disagreement to strong agreement). Consensus was defined as ≥75% of participants scoring within the 7-9 range. RESULTS Consensus was achieved on the answers to all questions. Recommendations for the use of cyclosporine and methotrexate were agreed. Transitioning from a conventional systemic therapy to a biological agent may be done directly or with an overlap (if transitioning is required because of lack of efficacy) or potentially with a treatment-free interval (if transitioning is required for safety reasons). Combination therapy may be beneficial. Continuous therapy for patients on biologicals is strongly recommended. However, during successful maintenance with biological monotherapy, a dosage reduction may be considered to limit drug exposure, although this may carry the risk of decreased efficacy. Switching biologicals for reasons of efficacy should be done without a washout period, but switching for reasons of safety may require a treatment-free interval. CONCLUSION This consensus provides practical guidance on treatment optimization and transitioning for moderate-to-severe plaque psoriasis, based on literature reviews and the expert opinion of dermatologists from across the globe.
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Affiliation(s)
- U Mrowietz
- Department of Dermatology, Psoriasis-Center, University Medical Center, Schleswig-Holstein (Campus Kiel), Kiel, Germany
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Hendriks AGM, Keijsers RRMC, de Jong EMGJ, Seyger MMB, van de Kerkhof PCM. Combinations of classical time-honoured topicals in plaque psoriasis: a systematic review. J Eur Acad Dermatol Venereol 2012; 27:399-410. [PMID: 22779910 DOI: 10.1111/j.1468-3083.2012.04640.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite the availability of newer topical treatments, classical topical treatments for chronic plaque psoriasis still have an important position for selected patient populations. The vast majority of patients are treated with a combination of topicals. The question arises: what is the evidence behind these approaches? OBJECTIVES To systematically review all available literature on efficacy and safety of combinations of classical topical treatments in chronic plaque psoriasis, including all combinations with dithranol, coal tar and penetration enhancers, and ultimately, to propose recommendations for combination treatment. METHODS Standardized literature searches in PubMed, EMBASE and the Cochrane Controlled Clinical Trial Register, and allocation of the degree of evidence was carried out. RESULTS In total 2918 publications on topical combination therapy were revealed, of which 48 articles on combinations of classical treatments. In this article, the results concerning the 19 included publications are stated. The majority of combination regimens is at least as effective as monotherapies, and is generally well tolerated. CONCLUSIONS Methods of classical treatments are not standardized and different protocols in different treatment settings are used. Therefore the interpretation of study results cannot be generalized. Most evidence was found to recommend the use of a combination regimen of topical corticosteroids and salicylic acid, above monotherapy with either component. Also, the combinations of dithranol with superpotent corticosteroids or with coal tar may be preferred above both monotherapies. In case first-line treatments and systemic therapies are not effective or contraindicated, combinations of classical topicals may provide an important opportunity.
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Affiliation(s)
- A G M Hendriks
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Chiam LYT, de Jager MEA, Giam YC, de Jong EMGJ, van de Kerkhof PCM, Seyger MMB. Juvenile psoriasis in European and Asian children: similarities and differences. Br J Dermatol 2011; 164:1101-3. [PMID: 21418172 DOI: 10.1111/j.1365-2133.2010.10196.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The first manifestations of psoriasis begin in childhood in more than one-third of patients. However, epidemiological data of juvenile psoriasis are lacking. OBJECTIVES To compare Dutch (NL group) and Singaporean (SG group) children with psoriasis with the aim of studying the characteristics of juvenile psoriasis and to highlight similarities and differences between these different ethnic groups. METHODS Data were collected from 207 patients younger than 18 years diagnosed with psoriasis from Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands and the National Skin Centre, Singapore. RESULTS A striking difference in familial distribution was found, with more Dutch children having an affected family member (73·3% vs. 13·6%). Presence of itch and triggering factors were more common among Dutch children (80% vs. 14·2% and 33·3% vs. 7·4%, respectively). However, both groups shared similar triggering factors like stress and infections. Other similarities included mean age at presentation (NL group 11·3 years; SG group 14·1 years) and gender ratio (NL group, M/F 1 : 1·1; SG group, M/F 1 : 1·4). Plaque psoriasis was the most common type in both cohorts while guttate and pustular psoriasis were rare. In both groups, the head, followed by the limbs, was the most common site involved. Similar proportions of children in both countries had nail involvement and psoriatic arthritis was rare. CONCLUSIONS The disparity in familial distribution may point to genetic differences between the two groups. Further studies to evaluate this difference in familial distribution may contribute to the understanding of the pathogenesis of psoriasis.
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Affiliation(s)
- L Y T Chiam
- National Skin Centre, 1 Mandalay Road, Singapore 308205.
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de Jager MEA, de Jong EMGJ, Meeuwis KAP, van de Kerkhof PCM, Seyger MMB. No evidence found that childhood onset of psoriasis influences disease severity, future body mass index or type of treatments used. J Eur Acad Dermatol Venereol 2011; 24:1333-9. [PMID: 20337819 DOI: 10.1111/j.1468-3083.2010.03645.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In more than one-third of the psoriatic population, the first manifestations occur in childhood. Whether the age of onset of psoriasis influences the march of psoriasis is not known. OBJECTIVES To describe the epidemiology and clinical features as well as prescribed treatments and familial distribution in psoriasis depending on the age of onset of the disease. METHODS A structured questionnaire was sent to 5300 adult psoriatic patients. Respondents were divided into two groups: patients who experienced an onset of disease before the age of 18 [childhood onset psoriasis (COP)] and patients with an onset of disease from the age of 18 [adult onset psoriasis (AOP)]. RESULTS Questionnaires of 1926 (36.3%) patients were suitable for analysis. In 37.1% of patients, first signs of the disease occurred before the age of 18. COP occurs predominantly in females, has a longer delay in diagnosis and a higher frequency of familial distribution. The development of guttate and erythrodermic psoriasis in adulthood is more frequently seen in COP. In contrast to common belief, type of psoriasis in COP often remains the same from childhood to adulthood. There was no evidence found that getting psoriasis before the age of 18 years influences development of high body mass index in adulthood, disease severity in later life or type of treatments used. CONCLUSIONS The age of onset of psoriasis essentially does not influence the subsequent course of the disease in adulthood.
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Affiliation(s)
- M E A de Jager
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Evers AWM, Verhoeven EWM, Kraaimaat FW, de Jong EMGJ, de Brouwer SJM, Schalkwijk J, Sweep FCGJ, van de Kerkhof PCM. How stress gets under the skin: cortisol and stress reactivity in psoriasis. Br J Dermatol 2011; 163:986-91. [PMID: 20716227 DOI: 10.1111/j.1365-2133.2010.09984.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Psychological stressors might contribute to the severity of chronic inflammatory diseases such as psoriasis by dysregulating hypothalamic-pituitary-adrenal (HPA) axis activity. OBJECTIVES To evaluate the role of cortisol, a key component of the HPA axis, in reaction to psychological stress in patients with psoriasis. METHODS Serum cortisol, clinical indicators of disease severity (Psoriasis Area and Severity Index) and self-report measures of daily stressors were measured monthly for 6 months in 62 patients with psoriasis. RESULTS In addition to the previous findings in this sample showing that peak levels of daily stressors predicted an increase in disease severity a month later, the peak levels of daily stressors were also significantly associated with a lower cortisol level. Moreover, patients who persistently experienced higher levels of daily stressors had lower mean cortisol levels than patients who experienced lower levels of daily stressors. CONCLUSIONS Results suggest that daily stressors influence disease outcome in patients with psoriasis by affecting cortisol levels at moments of high stress. Furthermore, patients with persistently high levels of stressors seem to have a specific psychophysiological profile of lowered cortisol levels and may be particularly vulnerable to the influence of stressors on their psoriasis.
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Affiliation(s)
- A W M Evers
- Department of Medical Psychology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands.
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de Jager MEA, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. A cross-sectional study using the Children's Dermatology Life Quality Index (CDLQI) in childhood psoriasis: negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol 2011; 163:1099-101. [PMID: 20716218 DOI: 10.1111/j.1365-2133.2010.09993.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Juvenile psoriasis is a chronic and incurable skin disease that affects approximately 0·7% of children. OBJECTIVES To achieve more insight into the quality of life (QoL) in childhood psoriasis and to investigate whether disease severity scores correlate with QoL scores. METHODS All consecutive patients with juvenile plaque psoriasis (≤ 18 years old) who visited our outpatient department were included. At baseline, the Children's Dermatology Life Quality Index (CDLQI) questionnaire was completed and disease severity was assessed by the Psoriasis Area and Severity Index (PASI) and the Physician Global Assessment (PGA). RESULTS Thirty-nine patients were included in the study. A median CDLQI of 6 [interquartile range (IQR) 5–9] was reported. Median PASI was 6·3 (IQR 3·3–8·2) and median PGA was 2 (IQR 1–3). The correlation coefficient between PASI and CDLQI was 0·47 (P = 0·003), whereas the correlation coefficient between PGA and CDLQI was 0·51 (P = 0·001). CONCLUSIONS The negative effect on QoL in juvenile psoriasis was confirmed in the largest cohort presented up to now. The correlation between disease severity scores and disease-related QoL in children with psoriasis is only moderate. Therefore, both clinical outcome parameters (PASI, PGA) and measures of QoL (CDLQI) should be included in adequate, patient-oriented clinical decision making.
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Affiliation(s)
- M E A de Jager
- Department of Dermatology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands.
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de Jager MEA, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Dithranol therapy in childhood psoriasis: unjustifiably on the verge of falling into oblivion. Dermatology 2010; 220:329-32. [PMID: 20389024 DOI: 10.1159/000278241] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 01/19/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In childhood psoriasis, physicians aim for an effective and safe treatment such as with dithranol. This study presents the largest study of dithranol-treated patients described in the literature. OBJECTIVE The aim of the study was to determine the position of dithranol in the treatment strategy for psoriasis. METHODS All juvenile patients receiving dithranol treatment at our center were evaluated retrospectively. RESULTS Sixty patients (with 82 treatment episodes in total) were included. The mean age at the start of dithranol treatment was 11.1 years (range: 3.7-17.9 years). The result of the treatment was: excellent (3.7%), good (69.5%), moderate (8.5%), reasonable (13.4%) or disappointing (4.9%). Mild irritation was seen in 39%, and severe irritation in 63% of the patients. CONCLUSIONS Dithranol can be regarded as an efficacious and safe topical therapy for the treatment of childhood psoriasis. It is a valuable alternative topical treatment which should not be disregarded in the treatment regimen for childhood psoriasis and should be commenced before ultraviolet or systemic treatments are initiated.
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Affiliation(s)
- M E A de Jager
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Vissers WHPM, van Duijnhoven M, van Erp PEJ, de Jong EMGJ, van de Kerkhof PCM. The effect of alefacept on T‐cell subsets and cells expressing NK receptors in lesional psoriatic skin: The effects of monotherapy and combination treatment with calcipotriol. J DERMATOL TREAT 2009; 19:344-50. [DOI: 10.1080/09546630802050472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kroft EBM, Creemers MCW, van den Hoogen FHJ, Boezeman JBM, de Jong EMGJ. Effectiveness, side-effects and period of remission after treatment with methotrexate in localized scleroderma and related sclerotic skin diseases: an inception cohort study. Br J Dermatol 2009; 160:1075-82. [PMID: 19210503 DOI: 10.1111/j.1365-2133.2008.09017.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Detailed information is lacking on effectiveness of methotrexate (MTX) in sclerotic skin diseases, side-effects, and duration of remission after discontinuation. OBJECTIVES To determine effectiveness, side-effects and period of remission gained by use of MTX in sclerotic skin diseases. METHODS All patients with a sclerotic skin disease who were treated with MTX (group A) or MTX with corticosteroids (CS) (group B) between 1995 and 2007 were evaluated. Detailed information was collected on dosage and duration of MTX treatment, concomitant immunosuppressive medication and CS treatment, effectiveness, side-effects, duration of the remission period, and time until restart. RESULTS Fifty-eight patients (A, n = 47; B, n = 11) were evaluated. Clinical assessment revealed that 38 patients (81%) treated with MTX and 11 patients (100%) treated with MTX + CS showed improvement of sclerotic skin. After one treatment course 51% of the patients treated with MTX and 73% treated with MTX + CS reached remission status with a median follow-up time of 55 and 58 months. Patients showing relapse still responded to a second and even to a third course of MTX. Patients who showed a relapse had received a lower cumulative dose, due to a shorter period of treatment with MTX in the first course. Serious side-effects were seen in six patients (10%). CONCLUSIONS MTX was an effective treatment for various sclerotic skin diseases with a long period of remission and relatively low toxicity. Patients showing relapse still responded to a second and third course of MTX.
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Affiliation(s)
- E B M Kroft
- Department of Dermatology, Radboud University Medical Centre Nijmegen, St Radboud, PO Box 9101, NL-6500 HB Nijmegen, the Netherlands.
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Abstract
BACKGROUND For some high-need psoriatic patients, the efficacy of etanercept monotherapy is insufficient. In these cases it might be indicated to combine etanercept with other conventional treatments. Objectives To provide daily practice safety and efficacy data for etanercept and methotrexate combination therapy. METHODS Data were extracted from an existing database, which contains prospective safety and efficacy data of all patients who were treated with etanercept in clinical practice. A case was defined as a patient using etanercept and methotrexate simultaneously for an indefinite period during follow-up. For all cases, baseline data, Psoriasis Area and Severity Index (PASI) scores, adverse events and laboratory values were investigated. Furthermore, the influence of introduction and discontinuation of methotrexate on these parameters was analysed. RESULTS Fourteen patients with simultaneous use of etanercept and methotrexate were selected. In six patients, methotrexate was introduced after etanercept to avoid further psoriasis deterioration, which resulted in an improvement of psoriasis in four of these patients. Eight patients were on methotrexate therapy before start of etanercept. Discontinuation of methotrexate in six of these patients resulted in a decrease in PASI improvement in five patients. Etanercept combined with methotrexate was well tolerated, and only mild adverse events were reported. No clinically significant changes in laboratory parameters occurred. CONCLUSIONS Results show that combining etanercept with methotrexate is reasonable when efficacy of etanercept monotherapy is insufficient, or when rapid deterioration of psoriasis after abrupt discontinuation of methotrexate is expected. Laboratory values and adverse events were not different from what would have been expected when using methotrexate alone.
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Affiliation(s)
- R J B Driessen
- Department of Dermatology, Radboud University Medical Centre, PO Box 9101, 6525 GL Nijmegen, the Netherlands.
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Driessen RJB, Berends MAM, Boezeman JB, van de Kerkhof PCM, de Jong EMGJ. Psoriasis treatment with etanercept and efalizumab: clinical strategies influencing treatment outcome. Br J Dermatol 2008; 158:1098-106. [PMID: 18384440 DOI: 10.1111/j.1365-2133.2008.08514.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple trials have been conducted in which the safety and efficacy of different biological therapies for psoriasis have been studied. However, the treatment course in clinical practice is different from the setting in which trials are conducted. OBJECTIVES The evaluation of the efficacy, safety and adverse events of etanercept and efalizumab treatment in daily practice and the investigation of interfering clinical strategies that could be of influence on treatment outcome. METHODS A prospective cohort consisting of 101 patients with high-need psoriasis was followed for 2 years and analysed. Patients were treated with etanercept or efalizumab between February 2005 and May 2007. Efficacy, safety and adverse events were investigated. Furthermore, all accompanying factors of which an influence on treatment efficacy outcome was suspected were registered, including treatment interruptions, dosage adjustments and combinations of therapies. RESULTS Etanercept and efalizumab treatment was effective and safe in most patients. However, in many cases the treatment course was characterized by unsatisfactory efficacy (83%), necessitating combination therapies or dosage adjustments. Treatment interruptions occurred in 56% (etanercept 2x50 mg group), 84% (etanercept 2x25 mg group) and 10% (efalizumab-treated patients). CONCLUSIONS Treatment of high-need psoriasis patients in daily practice is highly different from treatment courses in clinical trials. Frequently applied clinical strategies such as treatment interruptions, dosage adjustments and combinations of treatments influence treatment outcome in routine treatment in comparison with randomized controlled trials. Information about treatment with these new drugs in daily clinical practice is important for adjusting treatment schedules and guidelines.
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Affiliation(s)
- R J B Driessen
- Department of Dermatology, Radboud University Medical Centre, PO Box 9101, 6525 GL Nijmegen, The Netherlands.
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Driessen RJB, Boezeman JB, van de Kerkhof PCM, de Jong EMGJ. Three-year registry data on biological treatment for psoriasis: the influence of patient characteristics on treatment outcome. Br J Dermatol 2008; 160:670-5. [PMID: 19210502 DOI: 10.1111/j.1365-2133.2008.09019.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The course of biological treatment in clinical practice may be highly different from treatment schedules in clinical trials. Treatment modifications and patient characteristics may influence treatment safety and efficacy. So far, long-term results from the use of biological treatment in clinical practice are lacking. OBJECTIVES To report short- and long-term efficacy and safety data on biologics, especially etanercept, used in daily clinical practice. Special attention has been paid to patient characteristics that may have influenced the response to therapy. METHODS Prospectively collected registry data of all patients with psoriasis treated with biologics in the Radboud University Nijmegen Medical Centre outpatient clinic were used for analysis. Patient and treatment characteristics were surveyed. Efficacy and safety of etanercept for up to 3 years were analysed. Moreover, the influence of patient characteristics on etanercept treatment response was studied. RESULTS The analysed cohort, consisting of 118 patients, went through 142 treatment episodes in total. Patients treated with biologics had an extensive medical history. Optimization of biological treatment was established in various ways, including treatment switches and introduction of concomitant therapies. Short-term etanercept efficacy analysis showed a mean Psoriasis Area and Severity Index (PASI) improvement at week 24 of 59.7%. No significant influence of gender, age, baseline PASI, body mass index, number of previous systemic therapies or duration of psoriasis was found on week 24 efficacy results, although trends were discernible. The efficacy of etanercept remained stable for up to 156 weeks. Long-term daily practice treatment with etanercept was only occasionally accompanied by major safety concerns. CONCLUSIONS The current study demonstrates that etanercept is able to improve psoriasis symptoms for a considerable time, and that serious side-effects are infrequent. The influence of patient characteristics on treatment response is limited.
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Affiliation(s)
- R J B Driessen
- Department of Dermatology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6525 GL Nijmegen, The Netherlands.
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Langewouters AMG, van Erp PEJ, de Jong EMGJ, van de Kerkhof PCM. Lymphocyte subsets in peripheral blood of patients with moderate-to-severe versus mild plaque psoriasis. Arch Dermatol Res 2007; 300:107-13. [PMID: 18157542 PMCID: PMC2254658 DOI: 10.1007/s00403-007-0819-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 11/25/2007] [Accepted: 11/26/2007] [Indexed: 11/12/2022]
Abstract
In several studies peripheral blood T-cells have been quantified, yet few data are available on lymphocyte subsets in moderate-to-severe psoriasis (in terms of extent and activity of lesions) versus mild psoriasis. The objective is to compare lymphocyte subsets in peripheral blood of patients with moderate-to-severe disease (PASI-score ≥12) to patients with mild disease (PASI-score <12) and to healthy subjects. By means of flow cytometry method, lymphocytes in peripheral blood of 27 patients with psoriasis and 10 healthy controls were characterized. The absolute number of total lymphocytes was markedly decreased in patients with moderate-to-severe psoriasis as compared to patients with mild disease and normal subjects. Cellcounts of all analysed subsets were found to be increased in more severe psoriasis, except for CD8+CD45RO+ cells. The under-representation of CD8+CD45RO+ cells is compatible with the dynamics of acquired immunity, which requires a time log after the relapse of the lesions to differentiate from CD45RA+ naive cells.
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Affiliation(s)
- A M G Langewouters
- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Evers AWM, Duller P, van de Kerkhof PCM, van der Valk PGM, de Jong EMGJ, Gerritsen MJP, Otero E, Verhoeven EWM, Verhaak CM, Kraaimaat FW. The Impact of Chronic Skin Disease on Daily Life (ISDL): a generic and dermatology-specific health instrument. Br J Dermatol 2007; 158:101-8. [PMID: 17999699 DOI: 10.1111/j.1365-2133.2007.08296.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In dermatological research and clinical practice, there is a need for comprehensive self-report instruments that assess a broad spectrum of health implications of chronic skin diseases, including generic and skin-specific aspects of disease-related quality of life. The advantages of dermatology-specific, multidimensional instruments over generic instruments or single-dimensional quality-of-life measures are in the detailed and specific information they provide about health areas that are affected by the skin condition and that may change through therapeutic intervention. OBJECTIVES The development of a multidimensional health status inventory for chronic skin diseases (Impact of Chronic Skin Disease on Daily Life, ISDL) is described. The dermatology-specific part of the inventory assesses dimensions of physical functioning, more specifically skin status, physical symptoms of itch, pain and fatigue and scratching responses as well as disease-related stressors like stigmatization. The generic part gauges dimensions of psychological functioning, disease-related impact, illness cognitions and social support by means of existing scales validated for other chronic diseases. METHODS Reliability and validity of the questionnaire were studied in various samples of patients with psoriasis and atopic dermatitis. RESULTS The ISDL showed high reliability and test-retest reliability in both patient groups. Convergent validity was indicated by moderate to strong correlations with other validated questionnaires. The scales proved sensitive to change both for dermatological ultraviolet B radiation therapy and cognitive behavioural treatment for itching. CONCLUSION With its convincing results for reliability and validity the present evaluation supports the usefulness and applicability of the instrument for different chronic skin diseases.
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Affiliation(s)
- A W M Evers
- Departments of Medical Psychology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Berends MAM, de Jong EMGJ, van de Kerkhof PCM, Gerritsen MJP. Dermatologists’ Adherence to the Guideline of the Dutch Society of Dermatology and Venereology with Respect to the Treatment with Methotrexate for Severe Chronic Plaque Psoriasis: Results from a Dutch Survey. Dermatology 2007; 215:45-52. [PMID: 17587839 DOI: 10.1159/000102033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 02/09/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 2003, the Dutch guideline 'Photo(chemo) therapy and systemic therapy for severe chronic plaque psoriasis' was established. OBJECTIVES To document how closely this guideline is followed in clinical practice with respect to the methotrexate (MTX) treatment and to formulate recommendations to adjust the guideline. METHODS A survey was conducted among Dutch dermatologists and residents in dermatology. The questionnaire assessed the knowledge of and the adherence to the guideline with respect to MTX treatment. RESULTS Fifty percent of the contacted dermatologists/residents responded. Fifty-two percent follow the guideline with respect to MTX. Liver biopsy and the frequency of blood investigations cause a discrepancy between guideline and reality. There is a lack of consensus between guidelines of the different specialisms concerning liver biopsy. CONCLUSION The need for liver biopsies in combination with the frequent check-ups and the lack of consensus between rheumatologists, hepatologists and dermatologists seem to restrict the adherence to the guideline.
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Affiliation(s)
- M A M Berends
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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