Reviewing Complex Cases: Concomitant PsO and PsA

In the first round of breakout sessions at the Horizons in Advanced Practice meeting in Las Vegas, Nevada, Omar Noor, MD, FAAD; Douglas DiRuggiero, DMSc, MHS, PA-C; and Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, focused on common challenges and innovations in treating plaque psoriasis and atopic dermatitis (AD). To foster collaboration and discussion around the cases, the meeting attendees were divided into 3 groups, with each Horizons chair moderating a session. In the first case, Noor presented a man aged 70 years with a 20-year history of psoriasis.

Case 2: Concomitant Psoriasis and Psoriatic Arthritis

DiRuggiero presented a case of a man aged 47 years with a history of moderate psoriasis for 3 years and a recent diagnosis at the time of psoriatic arthritis. The patient presented with 10% BSA, persistent psoriatic plaques, mild joint pain in his wrists and knees, and limited morning stiffness. He was not happy with his current topical therapies. His prior therapies included topical corticosteroids that provided partial control of his psoriasis, calcipotriene ointments, and nonsteroidal anti-inflammatory drugs for joint pain. The patient wanted to try a systemic therapy but was concerned about overall safety.

DiRuggiero reviewed with attendees the available therapeutic options for concomitant psoriasis and psoriatic arthritis:

• IL-23 inhibitors: risankizumab, guselkumab
• IL-12/-23 inhibitors: ustekinumab
• IL-17 inhibitors: secukinumab, ixekizumab
• TNF-α inhibitors: certolizumab, etanercept, adalimumab, infliximab

Real-World Studies

To determine the best therapeutic option for this patient, DiRuggiero reviewed the efficacy of an IL-23 inhibitor, guselkumab (Tremfya; Johnson & Johnson), in examples of real-world studies. A posthoc analysis of the phase 3 DISCOVER-2 trial (NCT03158285) by Coates et al evaluated biologic/JAK inhibitor–naive participants with active psoriatic arthritis (≥5 swollen/≥5 tender joints, C-reactive protein≥0.6 mg/dL) who were randomly assigned 1:1:1 to receive guselkumab every 4 or 8 weeks or placebo with crossover to guselkumab.

Baseline BSA was 18.2% for patients who received guselkumab every 4 weeks (n= 245) and 17.0% for patients who received guselkumab every 8 weeks (n= 248). At week 52, 77% of patients who received guselkumab every 4 weeks and 74% who received guselkumab every 8 weeks achieved PASI 90, respectively, and were maintained through week 100. At week 100, 59% of patients who received guselkumab every 4 weeks and 53% of patients who received guselkumab every 8 weeks achieved PASI 100, respectively.¹

The phase 3b, randomized, double-blind, placebo-controlled SPECTREM trial (NCT06039189) demonstrated that guselkumab resulted in clear or almost clear skin in most adults with low BSA plaque psoriasis with special site involvement who did not achieve clearance with topicals. The average patient had over 80% improvement from baseline for BSA and PASI compared with patients who received placebo. Additionally, 52.9% of patients achieved PASI 90 compared with 6.2% of patients who received placebo.²

An integrated analysis by Strober et al evaluated 11 phase 2/3 studies of patients with psoriasis and psoriatic arthritis (n= 4399). In the studies, guselkumab was generally administered as 100-mg subcutaneous injections at week 0, week 4, then every 8 weeks in psoriasis studies and at week 0, week 4, then every 4 weeks or every 8 weeks in psoriatic arthritis studies. The rates of adverse events were similar between the guselkumab and placebo groups regardless of sex, age (< 65 vs≥65 years), weight, and biologic history.³

Treatment Decision

DiRuggiero shared with attendees that regarding the current patient case, the clinician started the patient on guselkumab 100mg subcutaneously at weeks 0 and 4 and every 8 weeks after that. Six months after the initiation, the patient reported visual improvements in psoriatic plaques, with less joint pain and rare morning stiffness. The patient has had nasopharyngitis and 2 upper respiratory tract infections, but both were manageable with standard care. No serious or opportunistic infections were reported.

References

1. Coates LC, Gossec L, Zimmermann M, et al. Guselkumab provides durable improvement across psoriatic arthritis disease domains: post hoc analysis of a phase 3, randomised, double-blind, placebo-controlled study. RMD Open. 2024;10(1):e003977. doi:10.1136/rmdopen-2023-003977
2. New SPECTREM study findings reveal Tremfya (guselkumab) effectively clears overlooked and undertreated plaque psoriasis. News release. Johnson & Johnson. October 25, 2024. Accessed January 9, 2025. https://www.jnj.com/media-center/press-releases/new-spectrem-study-findings-reveal-tremfya-guselkumab-effectively-clears-overlooked-and-undertreated-plaque-psoriasis
3. Strober B, Coates LC, Lebwohl MG, et al. Long-term safety of guselkumab in patients with psoriatic disease: an integrated analysis of eleven phase II/III clinical studies in psoriasis and psoriatic arthritis. Drug Saf. 2024;47(1):39-57. doi:10.1007/s40264-023-01361-w