This activity is supported by Jointly provided by Live Webcast independent educational grants from Novartis Pharmaceutical Corporation and Celgene Corporation.
Psoriasis Clinical Update: Assessing the Latest Trial Data and Treatment Algorithms Paul S. Yamauchi, MD, PhD Clinical Assistant Professor of Medicine Division of Dermatology, David Geffen School of Medicine University of California, Los Angeles
Learning Objectives • Assess current and emerging therapies for the treatment of psoriasis and cite their clinical trial data • Examine alignment of managed care psoriasis treatment algorithms with recent clinical trial data
Chronic Plaque Psoriasis: A Multisystem Inflammatory Disease • Chronic relapsing immune-mediated inflammatory disease • Affects >3% of the US population • Affects multiple areas of the body • Up to 30% of patients with psoriasis develop psoriatic arthritis • Accompanied by significant clinical, social, and economic burden Psoriasis Fact Sheet. National Psoriasis Foundation Web site. https://www.psoriasis.org/sites/default/files/publications/PsoriasisFactSheet.pdf. Published February 2015. Accessed March 2018. About Psoriatic Arthritis. National Psoriasis Foundation Web site. https://www.psoriasis.org/about-psoriatic-arthritis. Accessed March 2018.
Plaque Psoriasis is the Most Common of the Five Recognized Variants Severity of Plaque Psoriasis • Plaque: scaly, erythematous patches, Mild Moderate Severe papules, and plaques that are sometimes pruritic; affects ~80% of patients • Inverse/flexural: lesions are located in the skin folds • Guttate: small papules with fine scale • Erythrodermic: erythema covering nearly the entire body surface area with varying degrees of scaling <3% of BSA 3% -10% of BSA >10% of BSA • Pustular: clinically apparent pustules Psoriasis Fact Sheet. National Psoriasis Foundation Web site. https://www.psoriasis.org/sites/default/files/publications/PsoriasisFactSheet.pdf. Published February 2015. Accessed March 2018.
Immunopathogenesis of Chronic Plaque Psoriasis Disease Initiation Disease Maintenance Psoriatic plaque Keratinocyte Environmental trigger activation and proliferation Stressed Angiogenesis Neutrophils Stress keratinocytes Microorganisms IL-17A Drugs IL-17F Trauma Tc17 IL-22 TNF- α TNF- α Smoking IL-2 IL-6 IFN- γ IL-1 β PSORS1 Naïve T cell IL-23R Dermal DC Th17 Activation IL-12 IL-12B Th1 Tc1 Th17 IL-17A Genetic predisposition IL-17F IL-23 Th2 IL-22 Lymph node TNF- α Th17 Macrophage IL-6 IL-1 β DC=dendritic cell; PSORS1=psoriasis susceptibiity 1; IL=interleukin; TNF=tumor necrosis factor. Gaspari AA, Tyring S. Dermatol Ther . 2015;28(4):179-93. Nestle FO, Kaplan DH, Barker J. N Engl J Med . 2009;361(5):496-509.
Individuals with Psoriasis are At Risk of Developing Other Chronic Conditions ↑ risk of poor self -esteem, Depression/Anxiety psychological stress, and anxiety due to their psoriasis 39% ↑ risk of CV mortality 70% ↑ risk of MI Cardiovascular Disease 56% ↑ risk of MI 346% ↑ risk (mild psoriasis) Obesity 123% ↑ risk (severe) 22% ↑ risk (mild) Metabolic Syndrome 98% ↑ risk (severe) 14% ↑ risk (mild) Diabetes 46% ↑ risk (severe) Ni C, Chiu MW. Clin Cosmet Investig Dermatol . 2014;7:119-32.
Assessing Psoriasis Severity Assessments Classification of Severity Mild disease: <3% BSA Body Surface Area Percentage of skin area involved Moderate disease: 3%–10% BSA (BSA) Severe disease: >10% BSA Lesion characteristics including erythema, scaling, induration Psoriasis Area and Severity Index Mild-to-moderate disease: (PASI) Location/distribution of lesions BSA ≤ 10 and PASI ≤ 10 (eg, hands, feet, face, genitals) and DLQI ≤ 10 Moderate-to-severe disease: Dermatology Life Quality Index (BSA >10 or PASI >10) Impact on psychological factors (DLQI) and DLQI >10 and quality of life Itch Severity Score (ISS) Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. JAMA Dermatol . 2013;149(10):1180-5. Menter A, Gottlieb A, Feldman SR, et al. J Am Acad Dermatol . 2008;58(5):826-50. Spuls PI, Lecluse LL, Poulsen ML, Bos JD, Stern RS, Nijsten. J Invest Dermatol . 2010;130(4):933-43. Both H, Essink-bot ML, Busschbach J, Nijsten T. J Invest Dermatol . 2007;127(12):2726-39. Mrowietz U, Kragballe K, Reich K, et al. Arch Dermatol Res . 2011;303(1):1-10. Majeski CJ, Johnson JA, Davison SN, Lauzon CJ. Br J Dermatol . 2007;156(4):667-73.
Treatment of Psoriasis: Establish Individualized Treatment Goals • Goals of treatment 1 Treatment • Clear the skin AEs • Minimize adverse events • Enhance patient quality of life Tailor • Address comorbidities Patient Therapy Patient Perception • Individualize therapy by involving of Severity the patient in treatment decision- making 1,2 Disease • Consider patient preferences when Severity selecting therapy 1,2 1. Schaarschmidt ML, Schmieder A, Umar N, et al. Arch Dermatol . 2011;147(11):1285-94. 2. Brezinski EA, Armstrong AW. Semin Cutan Med Surg . 2014;33(2):91-7.
Treatment Approach: Treat-to-Target Treatment Goal: Reduce BSA to ≤1% three months after initiating treatment 6 months + 3 months Initiate post-initiation Treatment post-initiation Yes No Yes No BSA ≤1% BSA ≤1% Modify therapy Modify therapy • Adjust dose • Adjust dose Continue Continue current current • Add another agent • Add another agent therapy therapy (combination therapy) (combination therapy) • Switch to a new therapy • Switch to a new therapy Armstrong AW, Siegel MP, Bagel J, et al. J Am Acad Dermatol . 2017;76(2):290-298.
Treatment Options for Psoriasis • Topical therapies Mild • Steroid creams • Vitamin D analogues • Vitamin A retinoids • Ultraviolet light/lasers Moderate • UVB • PUVA Severe • Systemic therapies • Traditional/biologic DMARDs Psoriasis Severity Psoriasis Treatments. National Psoriasis Foundation Web site. https://www.psoriasis.org/about-psoriasis/treatments. Accessed March 2018.
Disease Severity Guides Treatment Selection Plaque Yes Systemic Signs/symptoms of psoriasis Phototherapy +/- pharmacotherapy psoriatic arthritis? diagnosed No Severity of disease? Mild Moderate-to-severe No +/- Topical agents Phototherapy Effective? Yes Continue current therapy Menter A, Gottlieb A, Feldman SR, et al. J Am Acad Dermatol . 2008;58(5):826-50. Menter A, Korman NJ, Elmets CA, et al. J Am Acad Dermatol . 2009;60(4):643-59. Menter A, Korman NJ, Elmets CA, et al. J Am Acad Dermatol . 2010;62(1):114-35.
Traditional Systemic DMARDS Acitretin Cyclosporine Methotrexate • Vitamin A derivative • Blocks inflammatory • Competitive inhibitor (retinoid) cytokine production of dihydrofolate • Immunomodulatory and T-cell activation reductase and anti-inflammatory • Initial approval: 1997 • Interferes with nucleic activity acid synthesis • Modulates epidermal inhibiting lymphoid proliferation and proliferation differentiation • Initial approval: 1972 • Initial approval: 1996 Menter A, Korman NJ, Elmets CA, et al. J Am Acad Dermatol . 2009;61(3):451-85.
Risk-Benefit Ratios of Traditional DMARDs Efficacy Toxicity Cyclosporine Methotrexate Acitretin
Biologics and Small Molecules Approved for the Treatment of Moderate-to-Severe Psoriasis Therapeutic Target IL-17 TNF- α IL-17A IL-23 IL-12/23 PDE-4 Receptor Adalimumab Brodalumab Secukinumab Guselkumab Ustekinumab Apremilast Certolizumab Ixekizumab Tildrakizumab Pegol Etanercept Golimumab Infliximab Biosimilars TNF=tumor necrosis factor; IL=interleukin; PDE-4=phosphodiesterase Treatment Comparison. National Psoriasis Foundation Web site. https://www.psoriasis.org/sites/default/files/treatment_comparison_chart_7.pdf. Published December 2017. Accessed March 2018.
Biologics Approved for Moderate-to-Severe Chronic Plaque Psoriasis: PASI 75, 90, and 100 Scores PASI 75 PASI 90 PASI 100 100 Percent of patients achieving PASI 90% 90 86% 82% 82% 80 76% 73% 71% 71% 70 64% 59% 59% 75/90/100 58% 60 51% 50 45% 44% 41% 40 36% 35% 33% 30% 30 26% 20% 18% 20 14% 14% 10 7% 0 Methotrexate Etanercept Adalimumab Infliximab Ustekinumab Secukinumab Apremilast Ixekizumab Brodalumab Guselkumab Tildrakizumab 1 2 3 4 5 6 7 8 9 10 11 (Week 16) (Week 24) (Week 16) (Week 24) (Week 12) (Week 12) (Week 16) (Week 12) (Week 12) (Week 12) (Week 12) 1. Saurat JH, Stingl G, Dubertret L, et al. Br J Dermatol . 2008;158(3):558-66. 2. Leonardi CL, Powers JL, Matheson RT, et al. N Engl J Med . 2003;349(21):2014-22. 3. Menter A, Tyring SK, Gordon K, et al. J Am Acad Dermatol . 2008;58(1):106-15. 4. Reich K, Nestle FO, Papp K, et al. Lancet. 2005;366(9494):1367-74. 5. Papp KA, Langley RG, Lebwohl M, et al. Lancet . 2008;371(9625):1675-84. 6. Langley RG, Elewski BE, Lebwohl M, et al. N Engl J Med . 2014;371(4):326-38. 7. Otezla (apremilast) [package insert]. Summit, NJ: Celgene Corp.; 2017. 8. Taltz (ixekizumab) [package insert]. Indianapolis, IN: Eli Lilly and Co.; 2018. 9. Siliq (brodalumab) [package insert]. Bridgewater, NJ: Valeant Pharmaceuticals; 2017. 10. Tremfya (guselkumab) [package insert]. Horsham, PA: Janssen Biotech, Inc.; 2017. 9.Sun Pharma announces U.S. FDA approval of Ilumya (tildrakizumab-asmn) for the treatment of moderate-to-severe plaque psoriasis. [news release]. Princeton, NJ: Sun Pharma; March 21, 2018.
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