Pharmacogenetic biomarkers for secukinumab response in psoriasis patients in real-life clinical practice

BACKGROUND

Prediction of the response to a biological treatment in psoriasis patients would allow efficient treatment allocation.

OBJECTIVE

To identify polymorphisms associated with secukinumab response in psoriasis patients in a daily practice setting.

METHODS

We studied 180 SNPs in patients with moderate-to-severe plaque psoriasis recruited from 15 Spanish hospitals. Treatment effectiveness was evaluated by absolute PASI ≤3 and ≤1 at 6 and 12 months. Individuals were genotyped using a custom Taqman array. Multiple logistic regression models were generated. Sensitivity, specificity and area under the curve (AUC) were analysed.

RESULTS

A total of 173 patients were studied at 6 months, (67% achieved absolute PASI ≤ 3 and 65% PASI ≤ 1) and 162 at 12 months (75% achieved absolute PASI ≤ 3 and 64% PASI ≤ 1). Multivariable analysis showed the association of different sets of SNPs with the response to secukinumab. The model of absolute PASI≤3 at 6 months showed best values of sensitivity and specificity. Four SNPs were associated with the capability of achieving absolute PASI ≤ 3 at 6 months. rs1801274 (FCGR2A), rs2431697 (miR-146a) and rs10484554 (HLCw6) were identified as risk factors for failure to achieve absolute PASI≤3, while rs1051738 (PDE4A) was protective. AUC including these genotypes, weight of patients and history of biological therapy was 0.88 (95% CI 0.83-0.94), with a sensitivity of 48.6% and specificity of 95.7% to discriminate between both phenotypes.

CONCLUSION

We have identified a series of polymorphisms associated with the response to secukinumab capable of predicting the potential response/non-response to this drug in patients with plaque psoriasis.

The risk of hepatic adverse events of systemic medications for psoriasis: a prospective cohort study using the BIOBADADERM registry

BACKGROUND

Limited information is available regarding the risk of incident liver disease in patients with psoriasis receiving systemic therapies.

OBJECTIVES

To describe the liver safety findings of conventional and modern systemic therapies for moderate-to-severe psoriasis, and to compare the relative incidence rates of hepatic adverse events (AEs) for each drug.

METHODS

All the patients on the BIOBADADERM registry were included. Crude and adjusted incidence rate ratios (cIRR and aIRR, respectively) of hepatic AEs, using anti-TNF drugs as reference, were determined. Outcomes of interest were hypertransaminasemia, nonalcoholic fatty liver disease (NADFLD) and a group of other, less represented, hepatic AEs.

RESULTS

Our study included 3,171 patients exposed to systemic drugs (6279 treatment cycles). Incident hypertransaminasemia was the most frequent hepatic AE (incidence rate of 21 per 1000 patients-years [CI 95% CI 18-23]), followed by NAFLD (8 cases per 1000 patients-years [95% CI 6-10]). Methotrexate (aIRR 3.06 [2.31-4.4]; p = 0.000) and cyclosporine (aIRR 2.37 [1.05-5.35]; p = 0.0378) were associated with an increased risk for hypertransaminasemia when compared to anti-TNF-α agents. No differences were observed between different groups of biologics. Conventional therapies were not associated with new incident NAFLD.

CONCLUSIONS

Comparative information of the incidence of hepatic AEs could facilitate drug selection in moderate-to-severe psoriasis.

Dermatologists' Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations

Psoriatic arthritis is a common type of inflammatory arthritis found in up to 40% of patients with psoriasis. Because skin involvement usually precedes joint involvement, dermatologists play a key role in early detection. Early diagnosis is important for reducing the risk of irreversible structural damage, attenuating the deterioration of physical function, and improving patients' quality of life. This consensus statement was drafted by a group of 9 dermatologists and 1 rheumatologist to provide simple recommendations to help dermatologists screen for psoriatic arthritis in patients with psoriasis. The experts offer consensus-based guidelines that draw on a review of available scientific evidence and on experience acquired in routine clinical practice.

Real-world effectiveness and safety of apremilast in psoriasis at 52 weeks: a retrospective, observational, multicentre study by the Spanish Psoriasis Group

BACKGROUND

Little has been published on the real-world effectiveness and safety of apremilast in psoriasis.

OBJECTIVES

To evaluate the effectiveness, safety and drug survival of apremilast at 52 weeks in patients with moderate to severe plaque psoriasis or palmoplantar psoriasis in routine clinical practice.

METHODS

Retrospective, multicentre study of adult patients with moderate to severe plaque psoriasis or palmoplantar psoriasis treated with apremilast from March 2016 to March 2018.

RESULTS

We studied 292 patients with plaque psoriasis and 85 patients with palmoplantar psoriasis. The mean (SD) Psoriasis Area and Severity Index (PASI) score was 10.7 (7.0) at baseline and 3.0 (4.2) at 52 weeks. After 12 months of treatment, 73.6% of patients had a PASI score of 3 or less. In terms of relative improvement by week 52, 49.7% of patients achieved PASI-75 (≥75% reduction in PASI score) and 26.5% achieved PASI-90. The mean physician global assessment score for palmoplantar psoriasis fell from 4.2 (5.2) at baseline to 1.3 (1.3) at week 52. Overall drug survival after 1 year of treatment with apremilast was 54.9 %. The main reasons for treatment discontinuation were loss of efficacy (23.9%) and adverse events (15.9%). Almost half of the patients in our series (47%) experienced at least one adverse event. The most common events were gastrointestinal problems.

CONCLUSIONS

Apremilast may be a suitable alternative for the treatment of moderate to severe psoriasis and palmoplantar psoriasis. Although the drug has a good safety profile, adverse gastrointestinal effects are common.

Linguistic and Cultural Adaptation to Spanish of the Screening Tool Psoriatic Arthritis UnclutteRed Screening Evaluation (PURE4)

BACKGROUND AND OBJECTIVE

The 4-item Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) questionnaire is a useful tool for identifying patients with suspected psoriatic arthritis before referring them to a rheumatology department for confirmation. The original English version has good discriminant validity (sensitivity, 85.7%; specificity, 83.6%). We aimed to produce an adapted Spanish version of the PURE-4 for validation and use in Spain.

MATERIAL AND METHOD

We applied the method recommended by the International Society for Pharmacoeconomic and Outcome Research for the cultural adaptation of patient-centered measurement tools. The phases in the processes involved forward translation, reconciliation, back translation review, harmonization, cognitive debriefing and review, and proofreading.

RESULTS

We obtained the permission of the author of the original questionnaire. Two native-speaking translators translated the questionnaire into Spanish. Small changes, mainly in the way the items were expressed, were then made in order to reconcile the 2 translations. The questionnaire was then back translated to English and revised to achieve a version equivalent to the original. A Spanish translation derived from the revision was tested for understandability in 7 patients, and the final Spanish version was then produced. During the translation phases, the project manager and a scientific committee made up of a dermatologist and a rheumatologist reviewed the different versions. Team members exchanged information throughout the process, providing for harmonization and the quality control that guaranteed conceptual equivalence.

CONCLUSIONS

This adaptation of the PURE-4 questionnaire for use in Spain has been the first step toward using it in routine clinical practice. The standardized method we used ensures that the Spanish and the original versions are equivalent.

Initial results of ixekizumab efficacy and safety in real-world plaque psoriasis patients: a multicentre retrospective study

BACKGROUND

Ixekizumab (anti-IL17A) is effective as treatment for moderate-to-severe plaque psoriasis, but real-life data on effectiveness and safety are currently very limited.

OBJECTIVE

To evaluate the efficacy and safety of ixekizumab in a cohort of real-life plaque psoriasis patients.

METHODS

Retrospective chart review of 100 patients with moderate-to-severe plaque psoriasis treated with ixekizumab at seven Spanish dermatological centres.

RESULTS

According to the as observed analysis, the percentage of patients achieving a 75% and 90% of reduction from the baseline score of Psoriasis Area and Severity Index (PASI) was 87.5%-50.0% at week 12-16; 88.3%-58.4% at week 24 and 82.9%-58.5% at week 52, respectively. The mean ± standard deviation (SD) score of PASI at baseline was 12.9 ± 9.2, and it declined rapidly after ixekizumab administration to 1.9 ± 4.0 (P < 0.001) at week 12-16 and was maintained at 1.7 ± 4.1 and 1.8 ± 2.9 at week 24 and 52, respectively. Ixekizumab response was not affected by clinical variables like body mass index, disease duration or the presence of psoriatic arthritis. However, the bio-naive group showed significantly higher PASI 75 response rate at week 12-16 compared to patients previously exposed to biologic agents (P = 0.037). Twenty-six (26%) patients experienced adverse events (AEs) during the follow-up period, being most of them of mild-to-moderate intensity. The most common AE was local reaction at the site of injection (14/26; 53.8%). At the end of the observational period, 15 (15%) patients discontinued ixekizumab treatment due to limited clinical improvement (n = 11), adverse events (n = 3) or lost to follow-up (n = 1) within a mean ± SD time of 6.0 ± 3.9 months.

CONCLUSION

The present study illustrates the initial experience with ixekizumab in real-world clinical practice confirming its usefulness and safety in the management of plaque psoriasis patients.

Oral health and systemic inflammatory, cardiac and nitroxid biomarkers in hemodialysis patients

Background

Periodontal diseases have systemic inflammatory effects and have been adversely associated with cardiovascular diseases, which are also the most frequent cause of death in the end-stage renal disease. The aim of this cross-sectional study was to investigate the oral health and serum biomarkers among the hemodialysis (HD) patients in Slovenia.

Material and Methods

111 HD patients were periodontally examined and their sera were assayed for C reactive protein (CRP), cardiac troponin T (TnT), nitrite/nitrate (NOx) and antibody levels to A. actinomycetemcomitans and P. gingivalis. The association of oral health with systemic response was analyzed with Kruskal-Wallis test, Fisher’s exact test and multivariate linear regression.

Results

Bleeding on probing without periodontal pockets was present in 5.2%, calculus without periodontal pockets in 42.1%, shallow periodontal pockets in 39.5% and deep periodontal pockets in 13.2% of dentate patients. There were 28.8% edentulous participants. 63.1% of the patients had CRP levels higher than 3 mg/L and 34.2% higher than 10 mg/L. TnT was detectable in all participants, with 25.2% exhibiting levels higher than 100 ng/L. The median level of NOx was 43.1 µmol/L. Participants with higher CRP were more likely to be edentulous and have higher TnT levels. A direct association of oral health with TnT or NOx was not detected.

Conclusions

HD patients in Slovenia have compromised oral health and increased serum inflammatory and cardiac biomarkers. Edentulousness was an independent predictor for the increased CRP, indicating a need for improved dental care to retain the teeth as long as possible.

Key words:Periodontal diseases, edentulousness, C reactive protein, cardiac troponin T, nitric oxide.

Alopecia areata as another immune-mediated disease developed in patients treated with tumour necrosis factor-α blocker agents: Report of five cases and review of the literature

BACKGROUND

Tumour necrosis factor antagonists (anti-TNF-α) have demonstrated the efficacy in different chronic immune inflammatory disorders. Within the spectrum of adverse events, autoimmune diseases have been observed, including cases of alopecia areata (AA).

OBJECTIVES

The objective of the study is to characterize AA developed during anti-TNF-α therapy.

METHODS

We present five new cases and review all the cases reported in the literature (eleven).

RESULTS

One third of the cases had a positive (personal or family) history of AA. Most of them presented with rapid extensive AA, usually involving the ophiasis area. Prognosis was usually poor, with slight response to treatments. In the cases where anti-TNF-α therapy was maintained, the course did not seem to change.

CONCLUSIONS

Although rare, AA developed during anti-TNF-α therapy might be more frequent than suggested by reports of isolated cases. Personal and family history of autoimmune disease might alert clinicians to their possible development or relapse once the anti-TNF-α therapy is started.

[Production of interleukin-8 by circulating CLA+ T cells with skin tropism in patients with psoriasis and in healthy controls]

BACKGROUND

Psoriasis is an immune-mediated disease typically associated with cutaneous neutrophilic infiltration and Munro microabscesses. Interleukin (IL)-8 is one of the main neutrophil-attracting chemokines. Although keratinocytes have traditionally been considered to be the principal source of IL-8 in psoriasis, we present data that suggest that cutaneous lymphocyte associated antigen (CLA) + T lymphocytes synthesize this cytokine.

MATERIAL AND METHODS

Six patients with psoriasis and 6 healthy controls were studied. Immunomagnetic separation was used to isolate CLA+ and CLA- T lymphocytes and IL-8 and interferon (IFN)-gamma production was quantified for each cell subpopulation using enzyme-linked immunosorbent assay. Finally, gene expression of IL-8 was analyzed by reverse transcriptase-polymerase chain reaction.

RESULTS

CLA+ and CLA- T lymphocytes from patients with psoriasis and from controls showed a significantly increased production of IFN-gamma when activated, whereas only activated CLA+ T lymphocytes (from patients and controls) synthesized IL-8. The higher level of expression of IL-8 and IFN-gamma by CLA+T lymphocytes in comparison to CLA- cells was confirmed.

DISCUSSION

Previous studies have confirmed IL-8 production by T lymphocytes in inflammatory skin diseases with neutrophil-rich infiltrates, such as acute generalized exanthematous pustulosis, Behçet disease, and pustular psoriasis. We have confirmed the role of the subset of T lymphocytes with skin tropism (CLA+) in IL-8 production in nonpustular psoriasis.

[Adverse reactions during biological therapy for psoriasis: results of a survey of the Spanish Psoriasis Group]

BACKGROUND

Biologic therapies have been a major breakthrough in the treatment of psoriasis because they are more selective and have a better short-term and medium-term safety profile. There are reliable data to support both the efficacy and the safety of these drugs. However, it is always useful to report the clinical experience of dermatologists who are experts in the use of biologic agents to treat psoriasis, particularly with regard to their safety.

MATERIAL AND METHODS

We present the results of a survey administered to the members of Spanish Psoriasis Group and based on a series of questions referring to the clinical safety of these agents. A total of 988 patients treated with efalizumab, infliximab, etanercept, and adalimumab were reported by 15 members of the group.

RESULTS

There was a particularly high proportion of reactions (34%) to infliximab infusions. Blood test abnormalities were detected in 13.25% of patients and infections in 12.24%, with one case of pulmonary tuberculosis. Attention is drawn to the adverse effects profile of efalizumab: de novo arthritis in 5.8% and rebound in 20.9% of patients.

CONCLUSION

The safety data provided by our study should be taken into account in view of the large number of patients recruited by dermatologists experienced in the use of this type of therapy.

[Effector function of CLA(+) T lymphocytes on autologous keratinocytes in psoriasis]

BACKGROUND

Cutaneous lymphocyte antigen (CLA) is expressed by a subgroup of memory T cells that exhibit skin homing and are implicated in cutaneous T-cell-mediated diseases.

MATERIAL AND METHODS

Expression of genes associated with psoriasis was analyzed in keratinocytes taken from patients and healthy individuals and cultured under different conditions, including activation using supernatants from CLA(+) T lymphocytes activated with anti-CD3 and anti-CD28 antibodies.

RESULTS

Keratinocytes from psoriasis patients activated by CLA(+)T lymphocytes expressed higher levels of interferon-inducible protein 10, HLA-DR, intercellular cell adhesion molecule 1, and inducible nitric oxide synthase.

CONCLUSIONS

Our results suggest that we have developed an in vitro model that will allow analysis of the effector role of CLA(+) T lymphocytes on keratinocytes in psoriasis. This model may allow the identification of genes involved in the pathology of psoriasis through induction by CLA(+) T lymphocytes.

[Safety of adalimumab]

The safety data for adalimumab in psoriasis are similar to those described for other indications authorized for this drug. Most of the adverse effects observed (mainly, reaction at the injection point and upper respiratory tract infections) are of mild intensity and do not make it necessary to discontinue the drug. Serious adverse effects have been described in a low proportion of patients and include infections (tuberculosis and other opportunistic infections), lymphoproliferative conditions, autoimmune diseases and demyelinizing processes. Similar to other anti-tumor necrosis factor alpha (anti-TNFalpha) treatments, the experience with adalimumab only provides information regarding its middle term safety. Thus, some years are needed to verify these results in the longer term. Due to this, the patients who are candidates for the drug must be correctly screened and they must be closely monitored during the treatment period and until 5 months after it.

Aggressive multifocal Buruli ulcer with associated osteomyelitis in an HIV-positive patient

Mycobacterium ulcerans infection causes a skin disease known as Buruli ulcer (BU), a disorder manifested usually as a solitary and painless nodule or papule that progresses to massive necrotizing destruction and cutaneous ulceration. When healing occurs, it often results in disabling deformities. Buruli ulcer is considered the third most common mycobacterial disease in immunocompetent people, after tuberculosis and leprosy. Although the emergence of Buruli ulcer in Western African countries over the past decade has been dramatic, it has been scarcely reported in industrialized countries. We report a patient from Equatorial Guinea who was human immunodeficiency virus-positive, presenting aggressive and multifocal BU associated with an underlying destructive osteomyelitis, in which only an aggressive surgical approach yielded to a resolution of the disease. In a global world, with increasing migratory population fluxes, an increased awareness of dermatologists regarding the clinical, histopathological and microbiological features of BU is important in order to avoid significant delays in diagnosis and treatment.

[An evaluation of the impact of primary care reform on health]

OBJECTIVE

Evaluation of the impact of the reform of primary health care services on the population health.

DESIGN

Comparative analysis of mortality rates for the 1984-96 period in three zones of homogeneous socioeconomic level, assessing the effect of the differential development of the reform of public primary health care services.

SETTING

The study is restricted to the 23 health areas with lower socioeconomic status in the city of Barcelona (443092 inhabitants).

MEASUREMENTS AND MAIN RESULTS

The study areas are categorized in three groups, according to the sequence of the reform: reformed between 1984 and 1989, RAP1 zone, reformed between 1990 and 1991, RAP2 zone, and those still served by the old scheme in 1992, NORAP zone. General mortality rates are analyzed, and also mortality rates by those avoidable conditions. Significant differences among the three zones are initially visible. The mortality decline is 13.6% in the RAP1 zone and 10.3% in the NORAP zone, so that the decline in the RAP1 zone is 32% greater than in the NORAP zone. At the end of the study, mortality due to stroke and hypertension is lower in the RAP zones than in the NORAP zone. Perinatal mortality shows a clear decline in the three zones. No relevant changes are seen for tuberculosis or cervical cancer. Lung cancer mortality increases except in RAP1 zone where it declines, to the point that the excess mortality from that cause estimated by comparison with the NORAP zone in the initial phase of the study vanishes. Death rates from cirrhosis and motor vehicle accident decline in all zones.

CONCLUSIONS

There is a clear association between the process of reform of primary care and the decrease in general mortality in these zones of low socioeconomic level. These results suggest that the reform of primary health care services in Spain may have a significant impact in the mortality of the population of lower socioeconomic level. The study highlight the cost in health and human lives of maintaining obsolete and overburdened services for some segments of the population, and justify the need and urgency of completing the process of reform initiated in 1984 and still unfinished in 1999.