Optimizing Biologic Therapy for Psoriasis

Jeffrey Cohen, MD, and Hannah Rodriguez, MPAS, PA-C, presented the session, “Psoriasis Comorbidities,” on the second day of the APP Institute Dermatology 2024, providing guidelines for choosing appropriate biologics based on associated comorbidities.

Dr Cohen, an assistant professor of dermatology and biomedical informatics and data science and the director of the psoriasis treatment program at the Yale School of Medicine, emphasized the importance of tailoring biologic therapy to individual comorbidities and collaborating with specialists for optimal patient care. He

discussed several key areas, including:

• Psoriatic arthritis (PsA): PsA affects about 30% of psoriasis patients within a decade. Many biologics for psoriasis also treat PsA, including tumor necrosis factor (TNF) inhibitors and IL-12/23 inhibitors. Early screening and rheumatology referrals are advised.
• Inflammatory bowel disease (IBD): IL-17 inhibitors are contraindicated due to risks of exacerbating IBD. TNF inhibitors and IL-12/23 inhibitors are preferred.
• Hepatitis B and C: Biologic use in hepatitis B requires caution, particularly with TNF inhibitors in patients with active infection. Hepatitis C is generally safer with biologics.
• Congestive heart failure (CHF): TNF inhibitors may worsen CHF, especially in advanced stages. Other biologic classes are safer.
• Multiple sclerosis (MS): TNF inhibitors can exacerbate MS. Other biologics, including IL-12/23 and IL-17 inhibitors, have not shown significant harm.
• Malignancy: Biologic use in cancer patients should be individualized and discussed with oncologists. TNF inhibitors warrant caution due to links with lymphoma.

Next, Hannah Rodriguez, a physician assistant at the Pennsylvania Dermatology Group and president of the Pennsylvania Dermatology Physician Assistants, presented real-life scenarios to apply recent insights into biologic therapy selection for severe psoriasis. She focused on integrating comorbidity considerations into treatment choices and presented various case studies.

• Case 1: 30-year-old woman

- Patient profile: Severe scalp and extremity psoriasis (14% body surface area [BSA]), history of plantar fasciitis, planning a pregnancy.

- Considerations: Possible psoriatic arthritis, pregnancy. Avoid TNF inhibitors due to potential teratogenic effects. Certolizumab, shown to be safe during pregnancy, is recommended.

• Case 2: 68-year-old man

- Patient profile: Severe psoriasis with genital and scalp involvement, psoriatic arthritis, new CHF, past hepatitis C, family history of lymphoma.

- Considerations: Avoid TNF inhibitors due to CHF and lymphoma risk. Safe options include ustekinumab, guselkumab, secukinumab, ixekizumab, and bimekizumab. Ensure gastrointestinal clearance for hepatitis C.

• Case 3: 75-year-old man

- Patient profile: Severe psoriasis (10% BSA), history of prostate cancer, hypertension, and depression, joint pain with knee replacements.

- Considerations: Avoid TNF-alpha inhibitors due to prostate cancer. Safe options include IL-12/23 inhibitors, IL-23 inhibitors, and IL-17 inhibitors. Coordinate with oncology.

• Case 4: 22-year-old woman

- Patient profile: New-onset psoriasis possibly induced by anti-TNF therapy for Crohn disease, no psoriatic arthritis or other comorbidities.

- Considerations: Avoid TNF inhibitors. Safe alternatives include ustekinumab and risankizumab, which are also FDA-approved for Crohn’s disease.

Finally, Cohen and Rodriguez emphasized the importance of personalized treatment plans considering each patient’s unique comorbid conditions. Coordination with specialists and ongoing patient assessment are crucial for effective and safe psoriasis management.

For more meeting coverage, visit the APP Institute Dermatology 2024 newsroom.

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Reference
Cohen J, Rodriguez H. Psoriasis comorbidities. Presented at: APP Institute Dermatology; Aug 16–17, 2024; Virtual.