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For optimal result, begin treating with biologic while tapering conventional systemic therapy


Dallas - For psoriasis patients just starting treatment, as well as those who've had poor results from conventional systemic therapies, biologics are a good first-line treatment option. But what about those who've had good results with methotrexate and cyclosporine and are forced to consider alternatives?

Overlapping therapies Preliminary data from ongoing clinical studies suggest that overlapping therapies - beginning treatment with a biologic while tapering doses of conventional systemic therapies - is both safe and effective, says Alan Menter, M.D.

According to Dr. Menter, chief, division of dermatology, Baylor University Medical Center, Dallas, researchers are focusing on optimizing the use of biologics by combining them with existing therapies. He cites an open-label study examining the safety and efficacy of multiple courses of alefacept (Amevive, Biogen) in combination with other psoriasis therapies.

Safe transition This new data supports other research findings that evaluated strategies for safely transitioning patients from methotrexate and cyclosporine to alefacept.

In an open-label study of methotrexate, patients received alefacept 15 mg intramuscularly once weekly for 12 weeks; concurrently, participants' weekly methotrexate dose was tapered over an eight-week period. "The majority of patients - 83 percent - successfully made the transition and maintained or improved their PASI scores," says Dr. Menter.

In a separate open-label study of patients treated with cyclosporine, participants received 12 weekly injections of alefacept 15 mg. Concurrently, cyclosporine dosage was tapered to 3 mg/kg in weeks five to six of alefacept therapy, to 2.5 mg/kg over weeks nine to 12, and discontinued altogether with the final alefacept injection. Patients then entered a 12-week observation phase, after which they were eligible for a second course of alefacept 15 mg IM.

"Preliminary results from seven patients demonstrate that PGA scores remained stable during the dose tapering of cyclosporine, with no evidence of disease flare or rebound," says Dr. Menter. "The complete efficacy and safety results from these ongoing studies will provide further valuable insight into the management of other psoriasis therapies when used concurrently with alefacept."

Another option Biologics also present an option for incremental improvements in patients gaining some benefits from traditional therapies, says Dr. Menter. Similarly, conventional therapies may reduce the safety risks of some biologics.

"Retinoids and biologics are a good combination," he says. "Also, low-dose methotrexate can prevent the potential antibodies associated with infliximab (Remicade, Centocor) therapy and has also been used for years in combination with etanercept (Enbrel, Amgen/ Wyeth) for rheumatoid arthritis and psoriatic arthritis."

By the time most patients opt for systemic therapy, topical treatments no longer provide them any relief. However, Dr. Menter recommends to his patients that they supplement with topical treatments once they achieve 60 percent to 70 percent improvement from the systemic treatment.

"Half of the people with psoriasis who need systemic therapy currently aren't receiving it," concludes Dr. Menter. "But with all of the new treatment options, more and more are hearing about them and coming for help. Among dermatologists I think there's been some disappointment because most of the available biologics are slow to show results. But we've got to change our strategy from 'quick fix' to gradual, long-term control. Most biologics optimize after three to six months."

Still a possibility That's not to say that quick fixes aren't a future possibility, however.

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