Derm Week Review: Managing Moderate to Severe Psoriasis: Interleukin Inhibitors

In his session, “Optimal Management of Moderate to Severe Psoriasis with Interleukin Inhibitors,” presented at Dermatology Week 2022, Joel Gelfand, MD, MSCE, discussed the current treatment landscape for psoriasis using recent data on IL-12, IL-23, and IL-17 inhibitors.

Starting with secukinumab, an IL-17A inhibitor, Dr Gelfand noted that recent data showed 300 mg of secukinumab met the Palmoplantar Pustulosis Area and Severity Index (PPPASI) at 75 in palmoplantar pustular psoriasis but failed to meet primary endpoint at 16 weeks.

He continued with ixekizumab, another IL-17A inhibitor, by presenting data from a placebo-controlled phase 3 study focused on patients with moderate to severe genital psoriasis.

“This is an example of a case where there’s localized disease, less than 1% body surface area that still would be a good candidate for [a] systemic agent,” he stated.

He then listed biologics that are the best choices for achieving PASI 90 in people with moderate to severe psoriasis, mainly based on moderate to high certainty. They included:

• Infliximab
• Ixekizumab
• Risankizumab
• Guselkumab
• Secukinumab
• Brodalumab

He also included bimekizumab, which had low-certainty evidence.

Additionally, he shared select recommendations for TNF inhibitors from the 2019 AAD-NPF psoriasis/biologics guidelines, starting with etanercept, which should be used as a monotherapy option for moderate to severe nail and scalp psoriasis in adults. “For infliximab, they suggest administering it in either shorter intervals or at a higher dose for better disease control in adults. They recommended that adalimumab should have a maintenance dose of 40 mg per week for better disease control and could be used as a monotherapy to treat moderate to severe psoriasis on palms, soles, or nails.”

Dr Gelfand also shared the recommended guidelines for the following biologics:

• Ustekinumab at an alternate dosage or high-frequency injection for those with an inadequate response from the standard dosing.
• Secukinumab for adults with moderate to severe plaque psoriasis on nails or palmoplantar plaque psoriasis.
• Guselkumab as a monotherapy for adults with scalp, nail, and palmoplantar psoriasis.

Another important topic Dr Gelfand addressed was COVID-19 risk associated with psoriasis biologics. He noted that existing literature on COVID-19 outcomes, while reassuring, was very limited and large, long-term population-based studies with the appropriate comparator groups were needed.

He concluded this topic by sharing his recommendations for COVID-19 vaccines in patients with psoriasis, such as:

• Patients should take the first mRNA- COVID-19 vaccine for which they are eligible.
• Patients should continue their psoriasis and/or psoriatic arthritis biologics even when receiving the vaccine.
• Patients should get either of the following boosters if eligible:
  • 5 months post mRNA vaccine such as Pfizer eligible for 12 years of age and older, or Moderna for those 18 years of age and older
  •  2 months following Johnson & Johnson.
• Patients should consider holding off methotrexate for about 2 weeks after the booster.
• Use shared decision-making to consider a second booster in those 50 years of age and older following 4 months post booster dose.

Regarding the second booster dose, Dr Gelfand stated, “Essentially, the boosters work so well—the first booster that is—and the added benefit is pretty minimal unless the patient is increasingly old or has significant underlying comorbidities.”

Reference
Gelfand J. Optimal management of moderate to severe psoriasis with interleukin inhibitors. Presented at: Dermatology Week 2022; May 11-14, 2022; Virtual.