Evolving Landscape of Biologic Therapy for Pediatric Psoriasis

Pediatric psoriasis is a chronic inflammatory skin condition. Current treatment modalities include topical medications, phototherapy, and systemic drugs, including biological agents. In cases of moderate-to-severe psoriasis recalcitrant to other therapies, biological therapies are often an attractive option given their dosing schedules, safety profiles, and need for less frequent laboratory monitoring, when compared with traditional systemic therapies. This article reviews biological treatment options approved for pediatric psoriasis and identifies others actively under investigation.

Comparing Beta Cell Preservation Across Clinical Trials in Recent-Onset Type 1 Diabetes

Several immunotherapies have demonstrated endogenous insulin preservation in recent-onset type 1 diabetes (T1D). We considered the primary results of rituximab, abatacept, teplizumab, alefacept, high-dose antithymocyte globulin (ATG), low-dose ATG, and low-dose ATG ± granulocyte-colony-stimulating factor trials in an attempt to rank the effectiveness of the agents studied. C-peptide 2-h area under the curve means were modeled using analysis of covariance. The experimental treatment group effect for each study, compared with its internal control, was estimated after adjusting for baseline C-peptide and age. Percentage increase in C-peptide over placebo and the absolute difference within study were calculated to compare and contrast effect size among interventions. Low-dose ATG (55% and 103%) and teplizumab (48% and 63%) ranked highest in C-peptide preservation at 1 and 2 years, respectively. Low-dose ATG and teplizumab show the greatest impact on C-peptide preservation among recent new-onset T1D studies; these should be further explored as core immunotherapies in the T1D prevention setting.

Biological therapies (immunomodulatory drugs), worsening of psoriasis and rebound effect: new evidence of similitude

BACKGROUND

Employing the secondary action or adaptative reaction of the organism as therapeutic response, homeopathy uses the treatment by similitude (similia similibus curentur) administering to sick individuals the medicines that caused similar symptoms in healthy individuals. Such homeostatic or paradoxical reaction of the organism is scientifically explained through the rebound effect of drugs, which cause worsening of symptoms after withdrawal of several palliative treatments. Despite promoting an improvement in psoriasis at the beginning of the treatment, modern biological therapies provoke worsening of the psoriasis (rebound psoriasis) after discontinuation of drugs.

METHOD

Exploratory qualitative review of the literature on the occurrence of the rebound effect with the use of immunomodulatory drugs [T-cell modulating agents and tumor necrosis factor (TNF) inhibitors drugs] in the treatment of psoriasis.

RESULTS

Several researches indicate the rebound effect as the mechanism of worsening of psoriasis with the use of efalizumab causing the suspension of its marketing authorization in 2009, in view of some severe cases. Other studies also have demonstrated the occurrence of rebound psoriasis with the use of alefacept, etanercept and infliximab.

CONCLUSION

As well as studied in other classes of drugs, the rebound effect of biologic agents supports the principle of similitude (primary action of the drugs followed by secondary action and opposite of the organism).

Understanding the New Clinical Landscape for Psoriasis: A Comparative Review of Biologics

Background:

Encouraging results from clinical trials suggest that biologic therapies are effective treatments for psoriasis.

Objective:

The aim of our study was to evaluate the scientific evidence for the efficacy and safety of biologic drugs for psoriasis.

Methods:

The studies reviewed include data on the biologies alefacept, efalizumab, etanercept, and infliximab. This article reviews all data published in the dermatology literature listed in the MEDLINE database, as well as data presented as abstracts and posters at dermatology society meetings, including the annual meetings of the American Academy of Dermatology.

Results:

The majority of the studies used an improvement from baseline of 75% or more in the psoriasis area and severity index (PASI 75) as the primary measure of efficacy.

Conclusions:

Overall, biologics represent an important addition to the psoriatic therapies and have a great impact on the disease course and life quality of those afflicted with psoriasis.

Alefacept is Well Tolerated in Patients with Chronic Plaque Psoriasis

Traditional systemic treatments for moderate to severe chronic plaque psoriasis are often poorly tolerated and are associated with safety concerns that restrict their long-term use. Alefacept is a fully human fusion protein that selectively targets memory T cells, and it is expected to provide enhanced safety over traditional nonselective agents. The safety and tolerability profile of alefacept is reviewed using data from the clinical development program. The most common adverse events were similar among alefacept and placebo groups. As expected from its mechanism of action, alefacept reduced the number of CD4+ and CD8+ T cells, with selectivity for the memory subsets. This reduction was not associated with an increase in the incidence of infections. Alefacept was not immunogenic. Patients have received up to six courses of alefacept therapy and the safety and tolerability profile over multiple courses is similar to that of a single course. Alefacept offers hope for a safer means to provide long-term management of psoriasis.

Biologic Therapeutics in the Treatment of Psoriasis. Part 1: Review

Background:

Psoriasis is a chronic inflammatory skin disease principally mediated by activated T cells, which release proinflammatory cytokines with reactive epidermal changes in the skin, producing the characteristic lesions of psoriasis. New research into possible treatment options has been inspired by increased understanding of the pathophysiology of psoriasis and advances in immunology and molecular biology permitting the development of targeted, highly active biologic agents.

Objective:

The aim of this article is to review the efficacy and safety of five biologic therapeutics in the treatment of moderate to severe psoriasis and to provide practical guidelines for integration of these agents in the management of psoriasis.

Methods:

We searched MEDLINE (1966–2005) for articles containing the key words: alefacept, efalizumab, etanercept, infliximab, and adalimumab and searched recent conference abstracts.

Results:

Emerging immunotherapeutic agents (fusion proteins, recombinant cytokines, fusion toxins, or antibodies) target T cells or cytokines responsible for plaque formation that is characteristic of psoriasis. Alefacept is the first biologic to be approved in both the United States and Canada. More recently, efalizumab and etanercept and infliximab have been approved in the United States and Canada for plaque-type psoriasis. Adalimumab is currently in phase III clinical trials.

Conclusion:

These novel biologics offer an intriguing and effective treatment option for patients with moderate to severe psoriasis.

Alefacept provides sustained clinical and immunological effects in new-onset type 1 diabetes patients

BACKGROUND

Type 1 diabetes (T1D) results from destruction of pancreatic β cells by autoreactive effector T cells. We hypothesized that the immunomodulatory drug alefacept would result in targeted quantitative and qualitative changes in effector T cells and prolonged preservation of endogenous insulin secretion by the remaining β cells in patients with newly diagnosed T1D.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled trial, we compared alefacept (two 12-week courses of 15 mg/wk i.m., separated by a 12-week pause) with placebo in patients with recent onset of T1D. Endpoints were assessed at 24 months and included meal-stimulated C-peptide AUC, insulin use, hypoglycemic events, and immunologic responses.

RESULTS

A total of 49 patients were enrolled. At 24 months, or 15 months after the last dose of alefacept, both the 4-hour and the 2-hour C-peptide AUCs were significantly greater in the treatment group than in the control group (P = 0.002 and 0.015, respectively). Exogenous insulin requirements were lower (P = 0.002) and rates of major hypoglycemic events were about 50% reduced (P < 0.001) in the alefacept group compared with placebo at 24 months. There was no apparent between-group difference in glycemic control or adverse events. Alefacept treatment depleted CD4+ and CD8+ central memory T cells (Tcm) and effector memory T cells (Tem) (P < 0.01), preserved Tregs, increased the ratios of Treg to Tem and Tcm (P < 0.01), and increased the percentage of PD-1+CD4+ Tem and Tcm (P < 0.01).

CONCLUSIONS

In patients with newly diagnosed T1D, two 12-week courses of alefacept preserved C-peptide secretion, reduced insulin use and hypoglycemic events, and induced favorable immunologic profiles at 24 months, well over 1 year after cessation of therapy.

TRIAL REGISTRATION

https://clinicaltrials.gov/ NCT00965458.

FUNDING

NIH and Astellas.

Treatment of psoriasis and psoriatic arthritis

Skin and joint manifestations associated with psoriasis and psoriatic arthritis (PsA) can significantly impact a patient's quality of life. Successful treatment is imperative in order to improve signs and symptoms of the disease, and to alleviate physical or psychological distress. For patients with mild psoriasis with or without PsA, topical agents and targeted phototherapy are appropriate treatments for psoriasis. Systemic therapies, such as methotrexate and phototherapy are recommended options for patients with more severe psoriasis, but their long-term use is hindered by safety concerns. Advancements in understanding the pathogenesis of psoriasis, including the role of T cells and cytokines, have been crucial to the development of biological therapies. These target the immune system and are suitable options for patients with extensive disease. Biological therapies for the treatment of psoriasis include targeted therapies (alefacept) and anti-cytokine therapies (anti-tumour necrosis factor [TNF] therapies [adalimumab, etanercept, infliximab] and a monoclonal antibody against interleukin [IL]-12 and IL-23 [ustekinumab]). Patients with PsA should be treated appropriately in order to improve symptoms and inhibit structural joint damage. Non-steroidal anti-inflammatory drugs or local intra-articular injections of corticosteroids can be used successfully in patients with mild PsA; however, neither treatment prevents the development of structural joint damage. For patients with moderate to severely active PsA, disease-modifying antirheumatic drugs (such as methotrexate), TNF inhibitor treatments (adalimumab, etanercept, infliximab and golimumab) or their combination are considered first-line treatment. This review provides a brief overview of treatment options for psoriasis and PsA, with an emphasis on the efficacy and safety of anti-TNF therapies.

Costimulation blockade alters germinal center responses and prevents antibody-mediated rejection

De novo donor-specific antibody (DSA) after organ transplantation promotes antibody-mediated rejection (AMR) and causes late graft loss. Previously, we demonstrated that depletion using anti-CD3 immunotoxin combined with tacrolimus and alefacept (AMR regimen) reliably induced early DSA production with AMR in a nonhuman primate kidney transplant model. Five animals were assigned as positive AMR controls, four received additional belatacept and four received additional anti-CD40 mAb (2C10R4). Notably, production of early de novo DSA was completely attenuated with additional belatacept or 2C10R4 treatment. In accordance with this, while positive controls experienced a decrease in peripheral IgM(+) B cells, bela- and 2C10R4-added groups maintained a predominant population of IgM(+) B cells, potentially indicating decreased isotype switching. Central memory T cells (CD4(+) CD28(+) CD95(+)) as well as PD-1(hi) CD4(+) T cells were decreased in both bela-added and 2C10R4-added groups. In analyzing germinal center (GC) reactions in situ, lymph nodes further revealed a reduction of B cell clonal expansion, GC-follicular helper T (Tfh) cells, and IL-21 production inside GCs with additional belatacept or 2C10R4 treatment. Here we provide evidence that belatacept and 2C10R4 selectively suppresses the humoral response via regulating Tfh cells and prevents AMR in this nonhuman primate model.

Diabetes: Immunotherapy for T1DM--still not there yet

Alefacept, a fusion protein approved for psoriasis, has been trialled in patients with new-onset type 1 diabetes mellitus. However, the withdrawal of the drug from the US market and the unmet primary end point do not raise hope for this drug, even though some secondary end points were met and the study highlighted interesting immunological efficacy.

Targeting of memory T cells with alefacept in new-onset type 1 diabetes (T1DAL study): 12 month results of a randomised, double-blind, placebo-controlled phase 2 trial

BACKGROUND

Type 1 diabetes results from autoimmune targeting of the pancreatic β cells, likely mediated by effector memory T (Tem) cells. CD2, a T cell surface protein highly expressed on Tem cells, is targeted by the fusion protein alefacept, depleting Tem cells and central memory T (Tcm) cells. We postulated that alefacept would arrest autoimmunity and preserve residual β cells in patients newly diagnosed with type 1 diabetes.

METHODS

The T1DAL study is a phase 2, double-blind, placebo-controlled trial in patients with type 1 diabetes, aged 12-35 years who, within 100 days of diagnosis, were enrolled at 14 US sites. Patients were randomly assigned (2:1) to receive alefacept (two 12-week courses of 15 mg intramuscularly per week, separated by a 12-week pause) or a placebo. Randomisation was stratified by site, and was computer-generated with permuted blocks of three patients per block. All participants and site personnel were masked to treatment assignment. The primary endpoint was the change from baseline in mean 2 h C-peptide area under the curve (AUC) at 12 months. Secondary endpoints at 12 months were the change from baseline in the 4 h C-peptide AUC, insulin use, major hypoglycaemic events, and HbA1c concentrations. This trial is registered with ClinicalTrials.gov, number NCT00965458.

FINDINGS

Of 73 patients assessed for eligibility, 33 were randomly assigned to receive alefacept and 16 to receive placebo. The mean 2 h C-peptide AUC at 12 months increased by 0.015 nmol/L (95% CI -0.080 to 0.110) in the alefacept group and decreased by 0.115 nmol/L (-0.278 to 0.047) in the placebo group, and the difference between groups was not significant (p=0.065). However, key secondary endpoints were met: the mean 4 h C-peptide AUC was significantly higher (mean increase of 0.015 nmol/L [95% CI -0.076 to 0.106] vs decrease of -0.156 nmol/L [-0.305 to -0.006]; p=0.019), and daily insulin use (0.48 units per kg per day for placebo vs 0.36 units per kg per day for alefacept; p=0.02) and the rate of hypoglycaemic events (mean of 10.9 events per person per year for alefacept vs 17.3 events for placebo; p<0.0001) was significantly lower at 12 months in the alefacept group than in the placebo group. Mean HbA1c concentrations at week 52 were not different between treatment groups (p=0.75). So far, no serious adverse events were reported and all patients had at least one adverse event. In the alefacept group, 29 (88%) participants had an adverse event related to study drug versus 15 (94%) participants in the placebo group. In the alefacept group, 14 (42%) participants had grade 3 or 4 adverse events compared with nine (56%) participants in the placebo group; no deaths occurred.

INTERPRETATION

Although the primary outcome was not met, at 12 months, alefacept preserved the 4 h C-peptide AUC, lowered insulin use, and reduced hypoglycaemic events, suggesting efficacy. Safety and tolerability were similar in the alefacept and placebo groups. Alefacept could be useful to preserve β-cell function in patients with new-onset type 1 diabetes.

Cost effectiveness of biologic therapies for plaque psoriasis

BACKGROUND

During the last decade, the implementation of biologic agents has changed the therapeutic management of severe psoriasis. Biologic agents have clinically proven efficacy, but their use is associated with a much higher cost compared with traditional treatment options. Therefore, when assessing the use of these drugs for the treatment of psoriasis, it is important to consider their cost effectiveness.

OBJECTIVE

The objective of this study was to determine and compare the cost effectiveness of biologic agents with regard to the cost per patient achieving a minimally important difference (MID) in the Dermatology Life Quality Index (DLQI) and the cost per patient achieving a 75% improvement in the Psoriasis Area Severity Index (PASI-75).

METHODS

A PubMed literature search was conducted to identify studies describing the efficacy of all currently US FDA-approved biologic therapies. The cost effectiveness of each agent over a 12-week period was determined and a sensitivity analysis was performed. Based on clinical efficacy at 12 weeks, treatment paradigms were extrapolated to estimate cost-effectiveness ratios after 1 year of treatment. Pooled data on each biologic agent at different doses were compared in a one-way sensitivity analysis and in an extreme case scenario analysis.

RESULTS

Twenty-seven studies were included in the analysis. Intravenous (IV) infliximab 3 mg/kg was the most cost-effective biologic agent with respect to both the cost per patient achieving PASI-75 and the cost per patient achieving a DLQI MID. The next most cost-effective agents in terms of cost per patient achieving PASI-75 were subcutaneous (SQ) adalimumab 40 mg administered every other week (eow) after an 80-mg loading dose, SQ adalimumab 40 mg eow, and IV infliximab 5 mg/kg. In terms of cost per patient achieving DLQI MID, IV infliximab 5 mg/kg, SQ etanercept 25 mg once weekly, SQ etanercept 50 mg once weekly, and SQ adalimumab 50 mg eow after an 80-mg loading dose were the next most cost-effective agents behind IV infliximab 3 mg/kg. For both costs per patient achieving DLQI MID and PASI-75, alefacept was the least cost-effective agent up to a 10% level of variation at all doses except 0.025 mg/kg once weekly.

LIMITATIONS

This study was limited by the use of efficacy data from 12-week clinical trials that did not compare treatments head to head to determine relative efficacy and may not be generalizable to longer treatment periods. Additionally, the estimated cost of treatment did not take into account indirect costs or variations in costs due to insurance company price contracting.

CONCLUSIONS

Biologic treatments that were most cost effective were so in respect to both the cost per patient achieving DLQI MID and per patient achieving PASI-75. This suggests that the same agents that are effectively clearing the disease are also effective in improving the patients' subjective assessment of dermatology-related quality of life.

Failure of alefacept in the treatment of vitiligo

BACKGROUND

Vitiligo is a common acquired pigmentary disorder with a profound psychosocial impact. The exact pathogenesis of vitiligo is not fully understood; however, vitiligo appears to be an autoimmune disease involving T-cell-mediated melanocyte destruction. Recently, complete clearance of coexisting vitiligo without recurrence over 2 years was reported in 2 psoriasis patients treated with alefacept.

OBJECTIVE

To evaluate the safety and efficacy of alefacept in the treatment of vitiligo.

METHODS

After providing informed written consent, 4 adult patients with widespread vitiligo (covering a body surface area ≥5%) were treated with weekly intramuscular injections of 15 mg alefacept for 12 weeks. All patients were monitored clinically, by laboratory investigation, and by digital image analysis. All patients were followed up with for 24 weeks.

RESULTS

All patients tolerated alefacept well, without any adverse events. None of the patients showed any repigmentation. However, 1 patient developed new depigmented patches during treatment with alefacept.

LIMITATIONS

A pilot study with a small number of patients.

CONCLUSION

Alefacept as a monotherapy for vitiligo treatment did not result in any patient improvement, and further evaluation in larger studies may be required.

Biologic agents and oral diseases -- an update on clinical applications

Biologic agents are targeted immune modulating agents that have been widely used in the treatment of inflammatory and neoplastic conditions with favorable results. The purpose of this review is to provide an update on the biologic agents that have been used in the treatment of diseases that affect the oral mucosa. Identification of relevant data, case reports and case series was performed using the PubMed-MEDLINE database and electronic databases of accredited organizations such as the European Medical Agency, US Food and Drug Administration, and clinicaltrials.gov (USA). According to the literature, the use of biologic agents in patients with oral diseases is limited mainly to patients suffering from refractory forms of immune-mediated diseases of the oral cavity. Biologic agents were used in all cases as off-label indications. Patient's response varied, but in general biologic agents could be considered as a therapeutic option in patients with no other alternative. A point requiring extra precaution is their safety profile because severe life threatening infections are among their side effects. Another aspect that limits their broader use is their high economic cost. We aimed to provide a practical update for the clinicians who deal with oral diseases, covering as many aspects as possible of the applications of biologic agents in oral diseases reported to date.

A randomized controlled study of combination therapy with alefacept and narrow band UVB phototherapy (UVB) for moderate to severe psoriasis: efficacy, onset, and duration of response

BACKGROUND

Alefacept is an effective intermittent treatment for psoriasis that can provide long-lasting remissions. Combination therapy with narrow-band ultraviolet B (nbUVB) phototherapy may enhance treatment outcomes and accelerate the onset of clinical response.

OBJECTIVE

To assess the efficacy of alefacept in combination with nbUVB phototherapy compared to alefacept alone in subjects with moderate to severe psoriasis.

METHODS

Ninety-eight adults with moderate to severe psoriasis were randomized to treatment with alefacept 15 mg intramuscularly (i.m.) once weekly for 12 weeks alone or in combination with three times weekly nbUVB treatments in this prospective, open-label, assessor-blinded, randomized, multicenter, parallel-group, 36-week study.

RESULTS

A statistically significantly greater proportion of subjects in the alefacept plus nbUVB arm achieved the primary endpoint of PASI 75 at week 16 compared to subjects in the alefacept alone arm (44.9% vs 22.5%, P=0.032). Secondary outcomes were also in favor of the alefacept plus nbUVB group, including the proportion of subjects achieving a Physician Global Assessment (PGA) score of clear or almost clear at any time during the study (59.2% vs 34.7%, P=0.026) and reduction in percent body surface area (BSA) involved with psoriasis at week 16 (13.4% vs 8.0%, P<0.001). The onset of clinical response was significantly faster in the combination therapy group compared to monotherapy (mean time to PASI 75: 82 vs 107 days, P=0.007). Both treatments were generally well tolerated.

LIMITATIONS

Open-label, assessor-blinded study without a phototherapy-only treatment arm.

CONCLUSION

The addition of nbUVB to treatment with alefacept significantly enhanced and accelerated the clinical benefits of alefacept therapy and was generally safe and well-tolerated.

Treatment of nail psoriasis with TNF-α or IL12/23 inhibitors

Nail psoriasis appears to be an important source of psoriatic morbidity through physical impairment, pain, and cosmetic disturbances. Conventional treatment is often unsatisfactory. A systematic review of studies reporting the effect of TNF-α inhibitors and related drugs on nail psoriasis using the Nail Psoriasis Severity Index (NAPSI) as the outcome measure was therefore made. Data are available from randomized controlled trials (RCT) where NAPSI has been studied as a secondary outcome, as well as from case-series in which NAPSI has been the primary outcome studies suggest that adalimumab, briakinumab, etanercept, golimumab, infliximumab, and ustekinumab all improve NAPSI scores. No direct comparative RCTs are available in which NAPSI scores have been reported. The data further suggest that changes in NAPSI mirror changes in disease severity of other psoriatic manifestations, that is, in psoriatic arthritis and skin psoriasis. The effect only appears to be delayed due to the rate of growth of the nail plate.

Immunotherapies in dermatologic disorders

Treatment modalities and therapeutic response experience support the use of immunotherapy in the treatment of many diseases in all fields of medicine. The aim of this article is to conduct and present a review of literature on the use of immunotherapy in the treatment of skin diseases analyzing scientific literature available up to January 2012. Studies that presented evidence-based data were selected. The article discusses how blocking or reverting the effect of a specific immunologic disequilibrium can treat dermatoses and intends to transfer a large amount of immunotherapy knowledge into a historical perspective for physicians naive to immunotherapy practices.

Oral manifestations of psoriasis. Clinical presentation and management

Psoriasis is a chronic immune-mediated disease of unknown etiology that affects the skin and mucous membranes. According to the National Institutes of Health (NIH), approximately five million Americans, 3% of the population, have been diagnosed with psoriasis. Oral manifestations of psoriasis are less well recognized than skin lesions, and treatment for oral lesions is not standardized. This article will review the clinical presentation of skin and mucous membrane psoriasis, along with the therapeutic modalities available to oral health-care providers.

New drug targets in atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disorder characterized by eczematous skin lesions, pruritus and typical histopathological features. T cells are thought to play a key role, but B cells might also participate in the pathogenesis of AD. In two investigator-initiated pilot studies, we studied the effects of B cell depletion by monoclonal anti-CD20 antibody therapy or a reduction of activated T cells by LFA3-IgG fusion protein on moderate-to-severe AD. All patients treated with either rituximab or alefacept showed an improvement of their skin symptoms with a sustained effect after treatment. In both studies, histological alterations, such as spongiosis, acanthosis and dermal infiltrate, including T and B cell numbers, dramatically improved and the expression of IL-5 and IL-13 was reduced after therapy. Upon rituximab therapy, allergen-specific IgE levels were not altered and total serum IgE levels only slightly decreased. According to recent studies, neutralizing B and T cells products such as IgE or IL-5 might be effective in subgroups of patients with AD.

Iatrogenic effects of biologics for psoriasis

Use of the biologic agents in moderate to severe chronic plaque psoriasis has provided novel and highly efficacious treatment options. Generally less systemically toxic than more traditional agents, the risks and benefits for these agents must also be considered. We present a review of the iatrogenic effects associated with use of the biologic agents in psoriasis. Focus is placed on antitumor necrosis factor agents, because they are the most studied and commonly used agents, as well as T-cell modulators and interleukin inhibitors.

Alefacept therapy for nephrogenic systemic fibrosis: a case series

Nephrogenic systemic fibrosis (NSF) is a recently described systemic fibrosing disorder that develops in the setting of renal insufficiency. Exposure to gadolinium has been implicated in its development. While the primary manifestations are cutaneous, systemic fibrosis can also occur. Several anecdotal reports of successful treatment have been reported, but there is no consistently efficacious therapy. We report the improvement or stabilization of cutaneous disease in three patients with NSF using alefacept therapy.

An update on the diagnosis and management of psoriatic arthritis

Psoriasis is a common inflammatory disease with complex genetic background affecting approximately 2-3% of the population in the Western hemisphere. Around 20% of psoriasis patients also suffer from psoriatic arthritis (PsA). The clinical spectrum comprises a wide variety of arthritic manifestations ranging from dactylitis, peripheral symmetric or asymmetric mono-, oligo-, and polyarticular arthritis, spinal disease and enthesitis. As psoriasis precedes PsA in 75-80% of affected patients, dermatologists might play a pivotal role in early diagnosis of the disease. Furthermore, magnetic resonance imaging (MRI) scanning and ultrasonography have improved the radiological diagnosis of peripheral PsA, psoriatic spondylarthropathy and enthesitis. Besides the traditional treatment of PsA the introduction of biologics has led to a significant improvement in the treatment of the disease. To further improve diagnosis, treatment and quality of life in our patients suffering from PsA an excellent interdisciplinary collaboration between dermatologists, radiologists and rheumatologists is a necessity of utmost importance.

Selective targeting of human alloresponsive CD8+ effector memory T cells based on CD2 expression

Costimulation blockade (CoB), specifically CD28/B7 inhibition with belatacept, is an emerging clinical replacement for calcineurin inhibitor-based immunosuppression in allotransplantation. However, there is accumulating evidence that belatacept incompletely controls alloreactive T cells that lose CD28 expression during terminal differentiation. We have recently shown that the CD2-specific fusion protein alefacept controls costimulation blockade-resistant allograft rejection in nonhuman primates. Here, we have investigated the relationship between human alloreactive T cells, costimulation blockade sensitivity and CD2 expression to determine whether these findings warrant potential clinical translation. Using polychromatic flow cytometry, we found that CD8(+) effector memory T cells are distinctly high CD2 and low CD28 expressors. Alloresponsive CD8(+) CD2(hi) CD28(-) T cells contained the highest proportion of cells with polyfunctional cytokine (IFNγ, TNF and IL-2) and cytotoxic effector molecule (CD107a and granzyme B) expression capability. Treatment with belatacept in vitro incompletely attenuated allospecific proliferation, but alefacept inhibited belatacept-resistant proliferation. These results suggest that highly alloreactive effector T cells exert their late stage functions without reliance on ongoing CD28/B7 costimulation. Their high CD2 expression increases their susceptibility to alefacept. These studies combined with in vivo nonhuman primate data provide a rationale for translation of an immunosuppression regimen pairing alefacept and belatacept to human renal transplantation.

Treatment of moderate-to-severe psoriasis with alefacept for up to one year: a case series

BACKGROUND

Alefacept has an established efficacy and safety profile for 12 weeks of treatment of severe chronic plaque type psoriasis. The effectiveness and safety of longer-term continuous use is not well characterized.

METHODS

Fifteen subjects with moderate-to-severe chronic plaque type psoriasis were given weekly 15 mg alefacept injections for 16 consecutive weeks followed by monthly 15 mg injections for up to eight consecutive months, along with clobetasol propionate spray 0.05% twice daily for the first four weeks. Disease severity was measured using the Psoriasis Area and Severity Index (PASI) and the Investigator Global Assessment (IGA).

RESULTS

Mean PASI scores improved 33 percent overall during the first month with combination treatment. There was an overall 21 percent worsening in PASI scores after the transition from weekly to monthly medication administration. Of the 15 initially enrolled patients, 27 percent achieved PASI 75 by end of study. No patients achieved an IGA of 0 or 1 by end of study. Two major adverse events were reported: low CD4 count and severe allergic dermatitis.

CONCLUSION

Topical clobetasol propionate 0.05% was only partially effective at augmenting the early treatment effect of alefacept. The authors did not observe marked benefit or major side effects by continuing additional monthly alefacept treatments beyond 16 weeks of weekly treatment.

Alefacept treatment for chronic plaque psoriasis

Biologic agents were introduced during the past decade as a new class of treatments for chronic psoriasis. These agents provide therapeutic alternatives to traditional topical and systemic therapies. Alefacept, the first such biologic agent, was approved by the US FDA in January 2003 for the treatment of chronic plaque psoriasis. This review will discuss data from clinical trials that have provided new insights into the efficacy, safety, and cost effectiveness of alefacept as a treatment for psoriasis.

Treatment of moderate-to-severe plaque psoriasis

Psoriasis, a chronic common immune-mediated disease with frequent remitting/relapsing courses, has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. It is also associated with various co-morbidities resulting in a decreased life expectancy and remarkable socioeconomic costs. At least one third of the patients who suffer from it has moderate or severe psoriasis and require continuous treatment to control disease activity. The therapeutic approach in daily practice is usually determined by the severity of the disease. Whether the definition of disease severity is not always clear, there is a considerable number of patients requiring systemic treatment to control the symptoms of psoriasis. The treatment options available for the management of moderate-severe psoriasis have dramatically increased over the past decade, and now range from phototherapy to traditional systemic treatments to biologics. Available data from clinical trials and growing number of patients treated with biologics shows that this new agent are effective and relatively safe to control psoriasis, and are coupled with improved tolerability, convenience and improvement in quality of life. This review shortly presents the characteristics, safety and efficacy profile of the conventional and newer systemic drugs used in moderate-to-severe psoriasis.

European S3-guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

A mechanism-based classification of dermatologic reactions to biologic agents used in the treatment of cutaneous disease: Part 2

Biologic therapies are an efficacious new method of controlling a number of chronic conditions. Data regarding these medications continues to emerge, giving clinicians a greater understanding of their side effects profiles. The biologic agents used in dermatology, particularly the tumor necrosis factor-alpha inhibitors, have a number of varied dermatologic side effects. In this two-part article, we perform a review of literature regarding cutaneous side effects of infliximab, etanercept, adalimumab, rituximab, efalizumab, and alefacept. In this second part, we discuss injection site reactions, infusion reactions, vasculitis, drug-induced lupus erythematosus, psoriasiform lesions, rebound phenomenon, eczema, atopic dermatitis, and hypersensitivity reactions.

New treatments for psoriasis: Which biologic is best?

Psoriasis is a chronic, debilitating disease affecting not only the skin, but also having a significant impact on a patient's quality of life. The treatment of severe psoriasis is quite challenging due to the chronic, relapsing nature of the disease and the difficulties inherent in treatment planning. Though the biologics are perhaps the most promising of available psoriasis treatments, the decision to institute a given therapy may be fraught with complexity for the clinician. Patients now hear of these promising new treatments for psoriasis via print, television and radio advertising; they frequently come to their physician asking if they are eligible for any of these agents and, if so, 'which biologic is best?'. This paper attempts to determine the ideal biologic agent based upon several parameters: FDA- and EU-approved indications, therapeutic efficacy, impact on quality of life, cost-effectiveness, and safety profile. Certainly the physician is central to medical decision-making, though ultimately patient preference may play the largest role in determining the 'best' biologic agent. There is no single ideal biologic for all patients and a physician's job is to educate patients on the relative advantages and disadvantages of each agent. Through informed discussion, the clinician can help each individual patient decide which biologic agent is ideal for them.

Combination therapy with acitretin for psoriasis

Numerous therapies exist for the treatment of psoriasis. A complete understanding of the benefits and potential risks of all therapeutic options is requisite in selecting an appropriate regimen for each patient. This paper examines the effectiveness of combination therapy with acitretin in treating difficult cases of psoriasis, which may require systemic medication or phototherapy. Combination therapy is often more effective than any single agent, as medications with different mechanisms of action work synergistically. Furthermore, using lower doses of two treatments in combination can minimize the potential side effects from a single agent at a higher dose.

Monitoring patients treated with efalizumab or alefacept

Though alefacept and efalizumab do not have robust development for treating inflammatory disorders other than psoriasis, they provided important therapeutic options for patients with chronic plaque psoriasis. Alefacept is administered in 12-week cycles and requires routine monitoring of CD4 lymphocyte counts as apoptosis of memory T cells is a hallmark of its mechanisms of action. In contrast, it is recommended to conduct monthly complete blood counts for patients on efalizumab during the first few months of therapy; efalizumab is intended for continuous long-term therapy. Alefacept works extremely well for a smaller cohort of patients. We cannot yet predetermine those who will respond through many cycles of alefacept. Efalizumab works extremely well for approximately 40% of subjects, and possibly more when retreatment options are considered. Most important for patients on either therapy is appropriate intermittent clinical evaluations to ensure stable, safe, and effective therapy.

Alefacept in corticosteroid refractory graft versus host disease: Early results indicate promising activity

Steroid refractory graft versus host disease (GVHD) presents a significant therapeutic challenge due to the limited efficacy and safety of second-line treatments. Three patients with extensively pretreated, refractory GVHD were treated with a targeted anti-T-cell agent, alefacept, and demonstrated rapid and clinically significant improvement in their GVHD, facilitating tapering of corticosteroids. The pathological and immunohistochemical findings of GVHD also improved, validating our clinical impression. These preliminary findings indicate that alefacept may have beneficial activity in GVHD warranting further study.

The effect of topical corticosteroids in combination with alefacept on circulating T‐cell subsets in psoriasis

BACKGROUND

Novel therapies against psoriasis are emerging. Alefacept is such a treatment. It selectively targets the memory effector population of T cells and thereby diminishes the psoriatic plaques. In some cases, however, the use of alefacept as a monotherapy is not sufficient.

OBJECTIVE

In the present study we investigate the safety and efficacy of adding topical steroids to alefacept treatment during the initial 4 weeks.

METHODS

Peripheral blood was obtained from all patients and the presence of specific T-cell subsets was assessed by flow cytometry. Fourteen patients were included and treated with 15 mg alefacept intramuscularly for a period of 12 weeks. Each of them was randomized to use either betamethasone-dipropionate cream or a vehicle cream during the first 4 weeks of the alefacept course.

RESULTS

Additional topical corticosteroid treatment during the first 4 weeks of alefacept treatment does not have a beneficial effect on the clinical efficacy. Marked changes were seen in the absolute cell counts of various of the analysed T-cell subsets in peripheral blood after 12 weeks of alefacept, either with or without additional local steroid application. The CD45RO+, CD8+CD45RO+, CD8+CD161+, CD4+CD25+, CD4+CLA+ and CD8+CLA+ populations showed a statistically significant decrease immediately after the treatment period. Further analysis revealed that the addition of local steroid therapy to alefacept results in marked decreases of all T-cell subsets analysed in this study, in contrast to the addition of the vehiculum only.

CONCLUSION

Alefacept selectively targets the CD45RO+ lymphocyte population, as well as some other subpopulations of lymphocytes. This effect is independent of the use of additional topical therapy during the first 4 weeks. The extent of the decrease, on the contrary, is dependent on the use of corticosteroids.

Alefacept promotes co-stimulation blockade based allograft survival in nonhuman primates

Memory T cells promote allograft rejection particularly in co-stimulation blockade-based immunosuppressive regimens. Here we show that the CD2-specific fusion protein alefacept (lymphocyte function-associated antigen-3-Ig; LFA -3-Ig) selectively eliminates memory T cells and, when combined with a co-stimulation blockade-based regimen using cytotoxic T lymphocyte antigen-4 (CTLA-4)-Ig, a CD80- and CD86-specific fusion protein, prevents renal allograft rejection and alloantibody formation in nonhuman primates. These results support the immediate translation of a regimen for the prevention of allograft rejection without the use of calcineurin inhibitors, steroids or pan-T cell depletion.

[Novel biologics in treatment of psoriatic arthritis]

Psoriatic arthritis is an inflammatory joint disease associated with psoriasis. Due to difficulty for early diagnosis and lack of effective therapy, the disease leads to chronic course and frequent relapse. Patients may suffer from ankylosis,disability and even death. The past treatments neither can control the disease effectively, nor be capable of inhibiting the development of structural joint damage. Based on the current psoriasis pathogenesis, novel biologics have been developed,which can aim the specific targets, resulting in more effective and safer management for psoriatic arthritis.

Biologic survival

BACKGROUND

The results of long-term studies on the efficacy and safety profiles of the biologics for patients with psoriasis are starting to appear in the literature. Not only are the results promising for the biologics as a whole, but the high number of patients remaining in these clinical trials after extended periods of time, or retention, may also reflect additional benefits of these biologics. The aim of this review was to manuscript aims to compare rates of attrition for the various biologic therapies in pivotal clinical trials in order to assess and compare adherence of patients to long-term use of the different biologic agents, also known as biologic survival.

METHODS

An in-depth literature review was conducted using PubMed and MEDLINE. Randomized, controlled trials utilizing biologic agents as monotherapy for the treatment of psoriasis were analyzed for patient numbers over time. Studies which provided data on patient retention for at least 24 weeks were selected, graphed, and compared. Reasons for discontinuation were noted.

RESULTS

Nineteen trials were selected, graphed and charted to compare attrition rates of the various biologic therapies. Due to differences in sample size, study design, dosing regimens, study duration and limited data with regards to patient numbers, it is difficult to reach a definitive conclusion as to which biologic agent is associated with the lowest rate of discontinuation. However, given the data available, etanercept appears to be the most successful therapy in terms of patient retention in studies both greater than and less than 30 weeks. For the studies using various dosing regimens, intrastudy attrition rates are also compared.

CONCLUSION

While the data available thus far on patient retention for the biologic therapies are very limited, preliminary conclusions can be drawn. Among the available biologic agents, etanercept appears to be associated with the lowest rate of discontinuation. This may be due to greater superior effiacy and to a decreased likelihood of experiencing adverse events.

Management of moderate to severe plaque psoriasis (part 2): clinical update on T-cell modulators and investigational agents

This second part of a 2-part review on the use of biologics for treatment of patients with psoriasis is focused on currently approved therapies that work through modulation of T cells: alefacept, a leukocyte function-associated antigen 3-immunoglobulin G fusion molecule; and efalizumab, an anti-CD11 humanized antibody. Efficacy and safety data from pivotal clinical trials are summarized and new data are presented for these biological agents, and considerations for optimal therapeutic selection are discussed. Clinical data from investigational agents currently in development are also reviewed. One of these new agents is ustekinumab, a humanized antibody that targets interleukins 12 and 23 and inhibits the differentiation of Th17 cells, a recently identified subset of CD4+ T-helper cells.

[Update in treatment of psoriatic arthritis]

Psoriatic arthritis is a chronic rheumatic disease making part of spondylarthropathies. It is the most frequent chronic inflammatory rheumatism after rheumatoid arthritis. Eventhough, it is usually a benign affection, it may be destructive leading to handicap. Several new medications have been introduced, including anti-tumor necrosis factor (TNF alpha blockers) and leflunomide for treatment of psoriatic arthritis. Many studies show the efficacy of these medications in this disease.

Biological agents in the treatment of psoriasis

Psoriasis is a chronic immune-mediated inflammatory disease, with an estimated prevalence of 1-3% worldwide. It is considered to be a multisystemic disorder, primarily affecting the skin and joints (psoriatic arthritis), and associated with other inflammatory conditions such as inflammatory bowel disease and coronary heart disease among others. Today, thanks to recent scientific advances that have allowed us to deepen our understanding of the pathogenesis of psoriasis, we count with an expanded therapeutic armamentarium that includes targeted therapy in the form of ''biologics''. These agents have gained popularity as safe, effective, and convenient alternatives for the treatment of chronic moderate to severe plaque psoriasis. This review will focus on the main biologics used in the treatment of moderate to severe plaque psoriasis: efalizumab, alefacept, etanercept, infliximab, adalimumab and the new Interleukin (IL) 12/23 inhibitors.

[Biologic therapy: a new and promising option to treat psoriasis]

The histologic and immunologic findings on psoriasis have led to the development of biologic therapies for its treatment. Biologic therapies are classified according to their structure as recombinant human proteins, monoclonal antibodies, and fusion proteins. Currently there are five biological drugs approved by the Food and Drug Administration for the treatment of psoriasis; however research studies are being performed to implement a few others. It is important to be familiarized with biological drugs, understand their mechanisms of action, and their adverse effects in order to be able to provide patients the most adequate therapeutical alternative. Advances in biotechnology provide new strategies that act on the immune system. The clinical experience using biological therapies in dermatology is relatively limited and there is a need to define which patients are candidates to receive these drugs. The combination of biologic treatments with traditional drugs needs further research since this could enhance their benefits, limit their toxicity, and reduce costs.

[Biological agents in treatment of psoriatic arthritis]

Psoriatic arthritis was reported in approximately 6-39% of patients with psoriasis. It is a chronic disease that commonly leads to disability. The paper reviews TNF-alpha inhibitors, the drugs which resulted in a substantial progress in management of psoriatic arthritis. Numerous studies have shown efficacy of these medical agents including inhibition of the disease progress, improvement of skin changes, inhibition of bone destruction, and improvement in quality of life. Other agents which can be used in psoriatic arthritis treatment are being tested in clinical trials.

Comparative effects of biological therapies on the severity of skin symptoms and health-related quality of life in patients with plaque-type psoriasis: a meta-analysis

BACKGROUND

The comparative effects of biological response modifiers (BRMs) on the severity of psoriasis and its effects on health-related quality of life (HRQoL) have not been evaluated.

OBJECTIVE

To conduct a meta-analysis to assess the effects of available biological agents on the severity of psoriasis, as well as to provide data on the effects of these agents on HRQoL.

METHODS

Medline and other databases were searched for randomized controlled trials (>or= 10 weeks' duration in adults) comparing biological therapies for moderate-to-severe psoriasis with placebo. A Mantel-Haenszel fixed-effects model was employed to estimate the pooled relative risks (RR) of patients achieving >or= 75% reduction of baseline Psoriasis Area and Severity Index (PASI 75) after >or= 10 weeks of treatment. Similar analyses were also conducted on PASI 50 and PASI 90. Using a random-effects model, we estimated the likelihood of achieving PASI 50, PASI 75, and PASI 90 at 10-12 weeks and 24 weeks. Data on the effects of different BRMs (vs. placebo) on HRQoL were also presented. Numbers (%) of patients discontinuing treatment were presented as a general index of drug tolerability.

RESULTS

Patients receiving infliximab 5 mg/kg intravenously at weeks 0, 2, and 6, then every 8 weeks, had the highest RR of achieving PASI 75, with a pooled RR value of 25.48 (95% confidence interval [CI], 14.04-46.23); followed by etanercept 50 mg administered subcutaneously (SC) twice weekly with RR = 11.92 (95% CI, 8.17-17.39); etanercept 25 mg SC twice weekly with RR = 10.68 (95% CI, 6.15-18.57); efalizumab 1-2 mg/kg SC per week with RR = 7.47 (95% CI, 5.20-10.73); and alefacept administered weekly (various doses) with RR = 3.37 (95% CI, 2.18-5.23). (All RR values were estimated vs. placebo.) Similar findings were observed with regard to proportions of patients achieving PASI 50 and PASI 90. The random-effects analysis suggested that infliximab significantly increased the likelihood of achieving PASI 50, PASI 75, and PASI 90 compared with placebo at 10-12 weeks; however, there were no significant differences between biological treatments at 24 weeks. Each BRM improved HRQoL compared with placebo according to findings from the Dermatology Life Quality Index. Proportions of patients discontinuing treatment were similar in active-treatment and placebo groups.

CONCLUSIONS

Infliximab significantly reduced disease severity by both fixed- and random-effects models. All biological therapies improved HRQoL compared with placebo, and proportions of patients discontinuing treatment were similar in active-treatment and placebo groups. The analysis is potentially limited by statistical factors and did not systematically account for different toxicity profiles, but the findings establish a foundation for head-to-head comparative trials.

Successful treatment of alopecia universalis with alefacept: a case report and review of the literature

Alopecia universalis often responds poorly to standard therapies. We report how a novel treatment option, alefacept, was successfully used in the management of a 21-year-old woman with alopecia universalis. The patient responded with complete regrowth of scalp and body hair after a single 12-week treatment course of alefacept. In addition, a review of the literature was performed pertaining to the use of biologic agents in the treatment of alopecia areata/universalis to determine which agents have a potential role in the treatment of this often refractory disease.

Alefacept for moderate to severe atopic dermatitis: a pilot study in adults

BACKGROUND

Atopic dermatitis is a common inflammatory skin condition with acute and chronic phases showing a prevalence of memory T cells. Alefacept is a fully human LFA-3/IgG1 fusion protein that inhibits T-cell activation and selectively reduces memory T cells, which may prove to be effective in the treatment of atopic dermatitis.

OBJECTIVE

We sought to evaluate clinical response of alefacept intramuscular (IM) injection for 16 weeks in adults with atopic dermatitis.

METHODS

This was an open-label study of a 16-week treatment regimen of alefacept IM injection in adults with moderate to severe inflammatory atopic dermatitis. Patients received alefacept (30 mg IM) weekly for the first 8 weeks. At week 9, patients who did not achieve a 50% reduction in their Eczema Area Severity Index (EASI) score continued on alefacept (30 mg IM) weekly; those patients with a 50% reduction in their EASI (EASI 50) score or higher had their weekly dose decreased (15 mg IM) for the remaining 8 weeks.

RESULTS

Nine patients with moderate to severe atopic dermatitis were enrolled and treated. At the primary end point, week 18, 1 patient achieved EASI 50 score and 1 patient achieved EASI 90 score; 4 patients had a decrease in EASI score of less than 50%, 1 patient had an increase in EASI score, and 2 patients withdrew early before the primary end point because of worsening disease. A Physician Global Assessment score of mild was achieved in 2 patients and 1 patient achieved a Physician Global Assessment score of almost clear. Minimal pruritus was reported by 3 patients and 1 patient reported no pruritus. The 16-week course of alefacept was well tolerated.

LIMITATIONS

The study was inherently limited by its small sample size, concomitant use of antihistamines, and open-label design, which increases the likelihood of observer and self-assessment bias.

CONCLUSION

The treatment regimen of alefacept for 16 weeks was well tolerated by our patients. Although, in this study, only 2 of the 9 patients with atopic dermatitis responded to treatment with alefacept, the study was inherently limited by the small sample size. Additional studies with a larger sample size, continued weekly use, or concomitant use of ultraviolet-B light therapy may be warranted to evaluate the possibility of alefacept as a therapy for patients with chronic atopic dermatitis.