Certain Biologic Treatments May Be Safer for Patients with Psoriasis

A new study conducted by researchers from Beth Israel Deaconess Medical Center (BIDMC) has found a decreased risk of infection in patients with psoriasis using newer, more targeted medications compared to those taking methotrexate, a drug widely used since the 1960s as a first-line treatment for moderate-to-severe psoriasis. The findings were presented at the Society for Investigative Dermatology meeting in Chicago.

This retroactive observational comparative cohort study, the largest of its kind, focused on the comparative risk of infection across 7 systemic biologics, new medications that inhibit the overactive immune system by targeting specific inflammatory pathways.

According to the study, the investigators used 2 large insurance claims databases of approximately 250 million patients in the United States. They then tracked the incidence of serious infection in approximately 107,000 patients with psoriasis who had a prescription for 1 of 7 systemic medications FDA-approved for the treatment of moderate-to-severe psoriasis including older systemic medications (acitretin and methotrexate), biologics (adalimumab, etanercept, infliximab, and ustekinumab), and a small-molecule inhibitor (apremilast).

In psoriasis, skin cells proliferate approximately 10 times faster than normal, causing the excess cells to build up into scaly thick patches of itchy, dry skin, particularly on the elbows, scalp, and knees. Certain immune system proteins, called cytokines, aid in causing psoriasis. Biologics work by inhibiting certain types of cytokines. Although earlier biologics, including adalimumab, etanercept, and infliximab, inhibited tumor necrosis (TNF)-alpha, which causes inflammation, newer biologics, including ustekinumab, work by blocking 2 proteins interleukin-17 and -23. By doing this, these newer biologics target the inflammatory pathways involved in psoriasis.

These newer agents have been shown to be more effective in treating psoriasis and could also be safer given their more specific action on the immune system. Apremilast, a newer non-biologic systemic treatment for psoriasis, does not directly inhibit inflammatory cytokines and is thought to have no increased risk of infection; however, it is generally less effective in treating psoriasis.

The most common types of serious infection were cellulitis, pneumonia, and bacteremia/sepsis among patients taking any systemic medications, according to the study. The investigators also found a decreased risk of serious infection with apremilast, etanercept, and ustekinumab compared with methotrexate. However, they did not find a different rate of overall infection among users of acitretin, adalimumab, and infliximab compared with methotrexate.

These findings suggest that biologics more specifically targeted to inflammatory pathways in psoriasis may be both more effective and safer when it comes to risk of infection, the investigators noted.

“This information should be considered when prescribing therapies for individual patients,” said lead author Erica D. Dommasch, MD, MPH, a dermatologist in the Department of Demartology at BIDMC, said in a press release. “This study demonstrates how researchers can use ‘big data’ to help compare the safety of different medications for patients with psoriasis.”