Psoriasis Updates: Comparing IL-23 and IL-17 Inhibitors, TNF Blockers

In his presentation at Maui Derm NP+PA Fall 2021, Bruce E. Strober, MD, PhD, discusses IL-23 and IL-17 inhibitors, TNF efficacy, and dosing changes in secukinumab.

In his presentation on psoriasis treatments at the Maui Derm NP+PA Fall 2021 conference, Bruce E. Strober, MD, PhD, of central Connecticut Dermatology, Cromwell, and clinical professor of dermatology, Department of Dermatology at Yale University, New Haven, Connecticut, discussed the different methods of treatment.

Before starting treatment, Strober explained the importance of classifying patients as either candidates for topical therapy or candidates for systemic therapy. The latter patients should meet the criteria of:

  1. Body surface area (BSA) > 10%.
  2. Disease involving special areas including face, feet, genitals.
  3. Failure of topical therapy improvement.

Currently, there are 3 approved interleukin (IL)-23 inhibitors:

  • Risankizumab
  • Guselkumab
  • Tildrakizumab

And 3 approved IL-17 inhibitors:

  1. Secukinumab
  2. Ixekizumab
  3. Brodalumab

In head-to-head studies, Strober explained that secukinumab showed rapid early onset efficacy, however, IL-23 inhibitors demonstrated greater long-term efficacy after 1 year.

“The points are very simple,” he said. “And that is early on, [secukinumab] are as fast or maybe even a little faster than the IL-23 inhibitors as a group. But over the long-haul, IL-23 numbers [show better sustained efficacy].”

Additionally, he said that tumor necrosis factor (TNF) inhibitors are, in his opinion, as efficacious as IL-17 inhibitors for psoriatic arthritis (PsA), however, they do not exhibit the same skin clearance as either IL-23 or IL-17 inhibitors.

“In 2021, if you have a patient with psoriasis and psoriatic arthritis, I'd like to see you consider more an IL-17 inhibitor and perhaps an IL- 23 inhibitor, but not a TNF blocker because we really want the skin to get better as well, and IL-17 and IL-23 work better in the skin,” Strober said.

He made it a point to highlight that most of these studies used secukinumab as the comparator. Notably, he said, if ixekizumab was used as comparator in studies, it would outperform secukinumab, making this il-17 inhibitor more competitive.

In his presentation, he also discussed a change in secukinumab dosing. The drug was tested for dosing every 2 weeks vs every 4 weeks, which is the normal dosing, after 5 induction doses for 16 weeks in patients weighing 90 kilograms or more.

This was done as an effort to make dosing flexible for patients weighing 90 kilograms or greater since secukinumab struggles in patients with higher weight.

“This tells you that essentially, secukinumab can be converted, as I like to say, to ixekizumab

when you give it every 2 weeks in patients weighing 90 kilograms or more, and I think this will be an updated part of the label on secukinumab in the coming year,” Strober concluded.

Reference:

1. Strober B. Psoriasis and Psoriatic Arthritis 2021. Session presented at: Maui Derm NP+PA Fall 2021 conference Program; September 30, 2021; Accessed September 30, 2021. Asheville, North Carolina.