Real-world effectiveness of adalimumab in patients with moderate-to-severe hidradenitis suppurativa: the 1-year SOLACE study

BACKGROUND

Long-term, real-word data are needed to help manage patients with hidradenitis suppurativa (HS) through this recurrent, painful and debilitating disease.

OBJECTIVES

To primarily measure real-world effectiveness of adalimumab in HS and to secondarily observe clinical course of HS in the light of patients' response.

METHODS

In SOLACE, adults with moderate-to-severe HS in need for change in ongoing therapy were treated with adalimumab for up to 52 weeks as per physician's medical practice. Treatment effectiveness was measured by Hidradenitis Suppurativa Clinical Response (HiSCR). Inflammatory nodules, abscesses and draining fistulas were counted, Hurley stage was assessed, and disease severity was rated using the International HS Severity Scoring System (IHS4). A post hoc analysis further explored the HiSCR response by abscess and inflammatory nodule (AN) count at baseline (low, medium and high) and gender. Spontaneously reported safety events were collected.

RESULTS

From 23 Canadian centres, 69% of the 138 patients achieved HiSCR at week 24, which increased to 82% and 75% at week 52 in patients with medium and high AN counts, respectively. Gender (4 times the odds for female) and age at HS onset (5% decrease with each additional year) had an effect on achieving HiSCR. Treatment with adalimumab led to an important decrease in number of lesions in responders, with most gains observed in inflammatory nodules, more frequently in the lower body area of patients in the high AN count group. The IHS4 scores of responders were substantially lowered, with a larger decrease in patients of the high AN count group. No new safety signal was detected.

CONCLUSIONS

The effectiveness of adalimumab was maintained during this 1-year period, and an optimal gain was documented for patients with medium and high AN counts. These real-world data support a prompt treatment of HS patients and the use of IHS4 to monitor treatment.

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group

Hidradenitis suppurativa (HS)/acne inversa is a debilitating chronic disease that remains poorly understood and difficult to manage. Clinical practice is variable, and there is a need for international, evidence‐based and easily applicable consensus on HS management. We report here the findings of a systematic literature review, which were subsequently used as a basis for the development of international consensus recommendations for the management of patients with HS. A systematic literature review was performed for each of nine clinical questions in HS (defined by an expert steering committee), covering comorbidity assessment, therapy (medical, surgical and combinations) and response to treatment. Included articles underwent data extraction and were graded according to the Oxford Centre for Evidence‐based Medicine criteria. Evidence‐based recommendations were then drafted, refined and voted upon, using a modified Delphi process. Overall, 5310 articles were screened, 171 articles were analysed, and 65 were used to derive recommendations. These articles included six randomized controlled trials plus cohort studies and case series. The highest level of evidence concerned dosing recommendations for topical clindamycin in mild disease (with systemic tetracyclines for more frequent/widespread lesions) and biologic therapy (especially adalimumab) as second‐line agents (following conventional therapy failure). Good‐quality evidence was available for the hidradenitis suppurativa clinical response (HiSCR) as a dichotomous outcome measure in inflammatory areas under treatment. Lower‐level evidence supported recommendations for topical triclosan and oral zinc in mild‐to‐moderate HS, systemic clindamycin and rifampicin in moderate HS and intravenous ertapenem in selected patients with more severe disease. Intralesional or systemic steroids may also be considered. Local surgical excision is suggested for mild‐to‐moderate HS, with wide excision for more extensive disease. Despite a paucity of good‐quality data on management decisions in HS, this systematic review has enabled the development of robust and easily applicable clinical recommendations for international physicians based on graded evidence.

Demography, baseline disease characteristics and treatment history of patients with psoriasis enrolled in a multicentre, prospective, disease-based registry (PSOLAR)

BACKGROUND

Psoriasis is associated with several comorbidities and behavioural risk factors.

OBJECTIVES

To evaluate demographic and disease characteristics in patients enrolled in the Psoriasis Longitudinal Assessment and Registry (PSOLAR).

METHODS

PSOLAR is a global, prospective, longitudinal, disease-based registry that includes a postmarketing commitment to evaluate safety in patients with psoriasis. Enrolled patients had to be receiving, or be eligible to receive, conventional systemic or biological agents. Demographic/disease characteristics, medical histories, lifestyle risk factors and previous treatments are collected at enrolment. Efficacy and safety data are collected every 6 months for 8 years, and data are extracted annually. Selected parameters are evaluated by age quartile using post hoc analyses.

RESULTS

As of 23 August 2012, 11 900 patients were enrolled at 301 sites in North America, Europe and Latin America. Over half of the PSOLAR population (54·7%) is male, with a mean age of 48·6 years and mean body mass index of 30·9 kg m(-2) at enrolment. Mean duration of disease at enrolment was 17·5 years, and mean Physician's Global Assessment score was 2·0. Psoriatic arthritis (35·5%) and cardiovascular diseases (38·2%) were highly prevalent. Diabetes mellitus type II was reported in 11·4% of patients. Depression and anxiety were noted in 14·7% and 11·1% of patients, respectively; 79·0% reported any alcohol use and 56·7% reported smoking or a history of smoking. The occurrence of most comorbidities, including cardiovascular disease and risk factors, increased with age.

CONCLUSIONS

In the PSOLAR population, multiple and age-appropriate comorbidities are associated with psoriasis and may affect the selection of psoriasis treatments.

Body fat percentage is associated with cardiometabolic dysregulation in BMI-defined normal weight subjects

BACKGROUND AND AIMS

Nearly 25% of normal weight individuals display abnormal metabolic profiles associated with obesity. As a wide range in body fat percentage (%BF) exists for BMI-defined normal weight individuals, we investigated whether elevated %BF (determined using DXA) was associated with cardiometabolic dysregulation among 977 normal weight subjects (192 men, 785 women) from the Canadian province of Newfoundland and Labrador.

METHODS AND RESULTS

BMI and %BF were measured after a 12-h fasting period. Cardiometabolic abnormalities considered included elevated triglyceride, glucose and hsCRP levels, decreased HDL cholesterol, insulin resistance, and hypertension. Subjects were classified as metabolically healthy (0 or 1 cardiometabolic abnormality) or abnormal (≥2 cardiometabolic abnormalities) and divided into sex-specific %BF tertiles as follows: low (≤15.2% men, ≤29.7% women), medium (15.3-20.7%% men, 29.8-34.9%% women) and high (≥20.8% men, ≥35.0% women). The prevalence of the metabolically abnormal phenotype was higher among medium and high %BF subjects (12.0% and 19.5%, respectively) compared to the low group (7.4%; p < 0.05). Furthermore, the odds of being metabolically abnormal were 1.61 (95% CI 0.94-2.77) for medium %BF subjects compared to the low group and nearly tripled for high %BF subjects (OR 2.73, 95% CI 1.63-4.86). ORs remained significant after further adjustment for waist circumference.

CONCLUSION

Our findings indicate that those with elevated %BF are at increased risk of developing cardiometabolic disease despite having a normal BMI. Future development of adequate screening tools to identify these individuals is crucial to the prevention of obesity-associated disease.

Long-term prognosis in patients with psoriasis

Psoriasis is a chronic, inflammatory, immune-mediated skin disease associated with substantial comorbidity. Traditional comorbid conditions include psychological/psychiatric disorders, psoriatic arthritis and inflammatory bowel disease. Increasingly, an association with metabolic dysfunction, including obesity and the metabolic syndrome, and cardiovascular disease, with consequent effects on morbidity and mortality, has been recognized in psoriasis. The underlying inflammatory mechanisms of both psoriasis and psoriasis-associated comorbidities involve mediation by proinflammatory T-helper type 1 cytokines. For effective management of psoriasis and related comorbidities, an integrated approach targeting both cutaneous and systemic inflammation may be beneficial, and strategies to improve overall management of the patient should be encouraged to reduce the disease burden. This paper discusses the emerging role of biological agents in this approach, and offers an appreciation of the role of existing anti-psoriasis and adjunctive therapies.

A review of biologic treatments for psoriasis with emphasis on infliximab

Moderate-to-severe psoriasis is known to affect millions of people around the globe. This chronic disease substantially impacts patients by impairing their quality of life, causing psychosocial distress, and creating an ongoing financial burden. The biologics are the newest and most effective therapeutic weapon in the treatment of moderate-to-severe psoriasis and psoriatic arthritis that can significantly alter the course of the disease in a relatively short period of time. There is a need to review the recommended treatment guidelines for moderate- to-severe psoriasis and psoriatic arthritis as the perception and demands of patients are constantly changing. Real world experience with this class of drugs is expanding and more new biologics are becoming available.

A new calcipotriol/betamethasone formulation with rapid onset of action was superior to monotherapy with betamethasone dipropionate or calcipotriol in psoriasis vulgaris

In this study, we compared a new combination ointment containing both calcipotriol and betamethasone dipropionate with betamethasone dipropionate ointment (Diprosone) and calcipotriol ointment (Daivonex) in patients with psoriasis vulgaris; 1106 patients were randomized to twice daily double-blind treatment with combination, betamethasone dipropionate or calcipotriol for 4 weeks. Patients then received twice daily calcipotriol, unblinded, for a further 4 weeks. Mean percentage change in PASI at end of the double-blind phase was -74.4 (combination group), -61.3 (betamethasone group) and -55.3 (calcipotriol group). Mean difference (95% Cl) combination-betamethasone was -13.1 (-16.9 to -9.3, p < 0.001) and for combination-calcipotriol -19.0 (-22.8 to -15.2, p <0.001). The differences in PASI were also statistically significant after 1 week. In the double-blind phase, 8.1% of patients (combination) reported lesional/ perilesional adverse reactions compared to 4.7% (betamethasone) and 12.0% (calcipotriol). In the combination group, mean PASI at the end of the double-blind phase was 2.5, and at end of the unblinded phase 3.6, compared with 3.9 and 4.1 (betamethasone) and 4.4 and 3.7 (calcipotriol). Calcipotriol/betamethasone combination is more effective and has a more rapid onset of action than either active constituent used alone, and is well tolerated. It is safe to transfer patients from combination to calcipotriol, with maintenance of clinical effect.

Best practices for the prevention and treatment of venous leg ulcers

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.

Web-based continuing medical education (I): field test of a hybrid computer-mediated instructional delivery system

The Internet and the World Wide Web (the Web) present exciting new possibilities for distributing educational materials at a distance and facilitating collaborative learning among geographically isolated physicians. This article provides a brief overview of the Web as an instructional delivery platform and discusses its strengths and weaknesses as a potential medium for enhancing distance learning opportunities for rural and remote physicians. It also describes an innovative hybrid instructional delivery model that was field tested by the Telemedicine Centre to determine its efficiency and effectiveness for providing Web-based instruction. A hybrid model merges the Web and CD-ROMs (compact disk read-only memory) to use several of the more valuable instructional components of Web-based education (i.e., multimedia, interactive forms, hypermedia, and computer-mediated communications). The results of the field test indicate that the hybrid delivery model was an efficient means for delivering computer-mediated continuing medical education instruction on dermatologic office procedures to a group of rural physicians in low telecommunication bandwidth regions.

Web-based continuing medical education. (II): Evaluation study of computer-mediated continuing medical education

BACKGROUND

Over the years, various distance learning technologies and methods have been applied to the continuing medical education needs of rural and remote physicians. They have included audio teleconferencing, slow scan imaging, correspondence study, and compressed videoconferencing. The recent emergence and growth of Internet, World Wide Web (Web), and compact disk read-only-memory (CD-ROM) technologies have introduced new opportunities for providing continuing education to the rural medical practitioner. This evaluation study assessed the instructional effectiveness of a hybrid computer-mediated courseware delivery system on dermatologic office procedures.

METHODS

A hybrid delivery system merges Web documents, multimedia, computer-mediated communications, and CD-ROMs to enable self-paced instruction and collaborative learning. Using a modified pretest to post-test control group study design, several evaluative criteria (participant reaction, learning achievement, self-reported performance change, and instructional transactions) were assessed by various qualitative and quantitative data collection methods.

RESULTS

This evaluation revealed that a hybrid computer-mediated courseware system was an effective means for increasing knowledge (p < .05) and improving self-reported competency (p < .05) in dermatologic office procedures, and that participants were very satisfied with the self-paced instruction and use of asynchronous computer conferencing for collaborative information sharing among colleagues.

Search for the psoriasis susceptibility gene: the Newfoundland Study

The authors review early pioneering research on the genetics of psoriasis and recently published independent and collaborative investigations searching for the psoriasis susceptibility genes. We describe the research design and current plans for a joint pursuit between the Psoriasis Research Institute, the Memorial University of Newfoundland, and Chiroscience R&D, Inc., for susceptibility genes. A unique study sample from Newfoundland, drawn from affected and unaffected members of multiplex families and relatives, provides a nearly homogeneous isolated population. Families reflect English, Scottish, and Irish ancestry, and have been in residence in Newfoundland for over 300 years. The prevalence of psoriasis is estimated to be 2 to 3%. Familial psoriasis occurs in over 85% of families, with at least one affected member. The experimental strategy using linkage analysis and linkage disequilibrium analysis of the collected tissue bank are discussed, emphasizing prospects for the future outcome of the research findings.

The role of Apligraf in the treatment of venous leg ulcers

A cultured, allogeneic, bi-layered human skin equivalent has recently become available to help clinicians manage difficult-to-heal venous ulcers. This skin equivalent has an epidermis and dermis similar to human skin. Its living keratinocytes and fibroblasts are from cultured cell banks derived from human neonatal foreskin. Because the skin equivalent is made up of viable human cells, it cannot be terminally sterilized. Safety concerns, which have been addressed, include the risk of possible transmission of infection, immunogenicity, immunological graft rejection, and tumor formation. However, the maternal blood of the neonatal donor and the master cell banks are screened for infectious agents. Additionally, the human skin equivalent is produced under strict aseptic control, with sterility continuously monitored by the Good Manufacturing Processes. This paper reviews the characteristics of this human skin equivalent and provides practice guidelines.

Oral terbinafine in the treatment of toenail onychomycosis: North American multicenter trial

BACKGROUND

Onychomycosis is an increasing problem with limited therapeutic options.

OBJECTIVE

We evaluated the safety and efficacy, of oral terbinafine, a new fungicidal antimycotic, in patients with toenail onychomycosis.

METHODS

A North American multicenter, double-blind, placebo-controlled study evaluated the mycologic and clinical efficacy of oral terbinafine 250 mg/day for 12 or 24 weeks in 358 patients with toenail onychomycosis.

RESULTS

A total of 74% of patients treated with 12 or 24 weeks of terbinafine achieved a successful clinical outcome. Approximately 11% of terbinafine responders showed evidence of relapse 18 of 21 months after cessation of treatment. Terbinafine was well tolerated; most adverse events were transient and mild to moderate in severity.

CONCLUSION

The results of this study confirm that oral terbinafine is a safe and effective therapy for the treatment of onychomycosis.

Effect of 1,25 dihydroxyvitamin D3 and calcium on growth and differentiation and on c-fos and p53 gene expression in normal human keratinocytes

Calcium enhances keratinocyte differentiation, and 1,25 dihydroxyvitamin D3 (1,25(OH)2D3) is both antiproliferative and prodifferentiative in many cell types, including normal human keratinocytes. In the present study, we examined the combined effects of calcium and 1,25(OH)2D3 on parameters of growth and differentiation and on c-fos and p53 gene expression in normal human keratinocytes. Exposure of normal human keratinocytes to 1,25(OH)2D3 markedly reduced [3H] thymidine incorporation and cell number at low and high medium Ca++ concentrations. Simultaneously, cells in the G0/G1 phase of the cell cycle increased significantly and those in the S phase fell precipitously. 1,25(OH)2D3 and calcium also induced keratinocyte differentiation independently, as assessed by immunocytochemistry and by induction of involucrin mRNA. Both Ca++ and 1,25(OH)2D3 were shown, by nuclear run-on assays, to increase involucrin gene transcription. A rapid, transient elevation in c-fos protooncogene expression preceded these effects when epidermal growth factor was present alone. When 1,25(OH)2D3 was added to quiescent keratinocytes, there was a marked augmentation of c-fos mRNA accumulation at low and high medium Ca++ concentrations. Varying medium Ca++ concentrations had no effect on c-fos mRNA levels. Increasing medium Ca++ concentrations from 0.15 to 2.0 mM produced marked elevations of p53 mRNA accumulation and of the rate of p53 gene transcription, whereas 1,25(OH)2D3 had no effect. These results, therefore, suggest that 1,25(OH)2D3 and calcium act in concert to modulate the expression of two important cell-cycle-associated genes, which may be important components in the initial programming of growth and differentiation of normal human keratinocytes.

Regulation of parathyroid hormone-like peptide in cultured normal human keratinocytes. Effect of growth factors and 1,25 dihydroxyvitamin D3 on gene expression and secretion

We have examined the expression and secretion of endogenous parathyroid hormone-like peptide (PLP) in primary cultures of normal human keratinocytes. In response to growth factors and fetal bovine serum, PLP mRNA expression and immunoreactive PLP release into conditioned medium was rapidly increased (within hours) whereas these effects were inhibited by 1,25-dihydroxyvitamin D3 [1,25(OH)2D3]. These early responses were not influenced by raising the medium calcium concentration from 0.15 to 1.0 mM. In contrast, increasing the medium calcium concentration to 1.0 mM, addition of 1,25(OH)2D3, or a combination of both, resulted in a delayed augmentation (after several days) in PLP production which was associated with an increase in cellular differentiation as assessed by production of high molecular weight keratin. To investigate whether these factors were acting at the level of transcription of the PLP gene, a series of vectors were prepared by fusing segments of the 5' flanking region of the rat PLP gene to a growth hormone reporter gene. Transient transfection of these constructs into cultured keratinocytes and measurement of immunoreactive growth hormone in the medium showed that a region stimulated by growth factors is located in a 1.9-kb fragment of the 5' flanking region and that a PLP gene promoter region less than 1.2 kb and greater than 0.3 kb upstream of the cap site contains cis-acting elements which respond positively to serum, and negatively to 1,25(OH)2D3. These combined studies demonstrate that, in normal human keratinocytes, growth factors may acutely stimulate PLP mRNA levels and PLP release, whereas 1,25(OH)2D3 inhibits these responses. At least part of these effects are at the level of gene transcription. Additionally, PLP synthesis and release are enhanced under conditions in which keratinocyte differentiation is induced.