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The systemic treatments of psoriasis are rapidly evolving as pharmaceutical companies continue their research to discover safer and more tolerable systemic medications for psoriasis patients.
Wailea, Hawaii - The systemic treatments of psoriasis are rapidly evolving as pharmaceutical companies continue their research to discover safer and more tolerable systemic medications for psoriasis patients.
Though some of the once hopeful drugs have come and gone, one expert says that the future is promising as emerging drugs raise the bar in terms of better efficacy and safety profile.
“Chronic immunosuppressive therapy is clearly becoming the standard of care in psoriasis, and the more drug development that occurs, the better it is for our patients and also our specialty. It’s all right that we have lost a few drugs over the years because this is a process of natural selection. The drugs that have remained however are looking very good,” says Craig Leonardi, M.D., clinical professor of dermatology, at Saint Louis University School of Medicine, St. Louis.
Alefacept, (Amevive, Astellas Pharma) efalizumab (Raptiva, Genentech) and briakinumab (Abbott) are three drugs that did not stand the test of time due to issues of efficacy and/or safety, says Dr. Leonardi, who spoke at MauiDerm.
Fortunately, though, the majority of the new drugs that come out are better and continue to improve on these fronts, such as etanercept (Enbrel, Amgen/Pfizer), infliximab (Remicade, Johnson & Johnson), adalimumab (Humira, Abbott) as well as ustekinumab (Stelara, Centocor).
The tumor necrosis factor (TNF) antagonists are the most commonly used systemic medications in patients with severe psoriasis and, according to Dr. Leonardi, this class of drug appears to currently be the safest choice of therapy, as they have a proven value over time coupled with very good safety data. Moreover, most are self-injected and therefore very easy to administer, especially when compared to intravenously administered medications, such as infliximab.
“In my opinion, the TNF antagonists remain the drugs of first choice and they do so because they treat the range of comorbidities associated with psoriasis such as psoriatic arthritis, and they are generally accepted to be cardioprotective,” he says. “In addition, there are over 2 million patients worldwide who are on these therapies right now, so there is a familiarity with the way the drugs perform as well as their established safety profiles.”
Due to the increased exposure to systemic immunosuppressants particularly in the setting of long-term therapy, however, psoriasis patients should be screened for a variety of infection-related issues such as hepatitis, Dr. Leonardi cautions, and it is possible that the current guidelines regarding clearing a patient for the administration of a given systemic medication or inclusion criteria for future clinical trials may change.
Currently, there are a variety of practice guidelines and recommendations for hepatitis B virus screening in patients who are being considered for long-term immunosuppressive therapy. Although the Food and Drug Administration warns against all TNF-alpha inhibitor therapy in patients with hepatitis B infection, the American Academy of Dermatology only recommends hepatitis B screening in the “appropriate setting,” Dr. Leonardi says. The American College of Rheumatology, however, does not recommend a universal screening but instead, only screening in “high-risk” patients and those patients treated with specific drugs.
Hepatitis B infection during immunosuppressive therapy could have serious outcomes, Dr. Leonardi says, and thus it would be wise to practice universal hepatitis B screening prior to long-term immunosuppressive drug therapy. According to Dr. Leonardi however, dermatologists should not treat hepatitis B patients with any systemic immunosuppressive drugs without having a hepatologist involved in the planning and management.
“Patients need to be treated for their hepatitis B infection before embarking on immunosuppressive therapy, and a timely prophylactic antiviral therapy could even improve outcomes,” he says.
Interestingly, hepatitis C is considered to be perfectly compatible with the TNF antagonist class of drugs, Dr. Leonardi says, and while TNF blockade makes hepatitis B worse, the drug can often help improve the hepatitis C status. Though counterintuitive, he says the actual viral load in the blood decreases in those patients with hepatitis C who also take TNF antagonists, in some cases dramatically.
“There are several different TNF antagonists that are showing promise right now and there surely will be more in the pipeline. Many people get wrapped up in these immunosuppressive drugs and the companies, but the fact is, we want good and safe medications for our patients and these agents appear to be doing well and are getting better all the time,” Dr. Leonardi says.
Disclosures: Dr. Leonardi is a consultant for Abbott, Amgen, Centocor, Pfizer and Eli Lilly. He has been an investigator for Abbott, Amgen, Genentech, Centocor, Eli Lilly, Pfizer and Novartis. He is on the speakers’ bureau for Abbott and Amgen.
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