Adalimumab in Chronic Plaque Psoriasis: A Clinical Guide
August 2017 | Volume 16 | Issue 8 | Original Article | 779 | Copyright © August 2017
Jashin J. Wu MD FAADa and W.C. Valdecantos MDb
aKaiser Permanente Los Angeles Medical Center, Los Angeles, CA bAbbVie, North Chicago, IL
Psoriasis is a common, inflammatory disease that manifests itself as lesions on the skin, which greatly impacts the physical and psychological wellbeing of those affected. The current goal of treatment in psoriasis is to improve the signs and symptoms of disease, whilst minimizing the burden of disease on patient health-related quality of life. Psoriasis can also be associated with other comorbidities such as joint disease, cardiovascular disease, and depression, which can add to the complexity of treatment.
Adalimumab is a recombinant, fully human, monoclonal antibody against tumor necrosis factor alpha (TNF-α), which blocks the interaction of TNF with both of its cell-surface receptors, with high affinity and specificity. Adalimumab is well established for the treatment of moderate–severe chronic plaque psoriasis in adults, and has more recently been approved in the European Union for use in pediatric patients with severe chronic plaque psoriasis.
Here we provide a clinical guide for adalimumab and review existing data on the efficacy and safety of originator adalimumab in moderate–severe chronic plaque psoriasis in adult and pediatric patients. We discuss short- and long-term treatment with adalimumab, and efficacy in hard-to-treat psoriasis of the scalp, hands, feet, and nails, in addition to the impact on associated pain and pruritus. We also discuss treatment optimization with adalimumab in the context of relevant clinical scenarios, and treatment of complex patients with underlying comorbidities. Finally, we examine available real-world clinical data for adalimumab in psoriasis.
J Drugs Dermatol. 2017;16(8):779-790.
Psoriasis is a chronic, immune-mediated, inflammatory disease that affects the skin (including the scalp, hands, and feet) and the nails. It affects between 1.5–5% of the population in developed countries,1 with the most common symptoms reported by patients being pain, itch, and bleeding of skin lesions.2 Plaque psoriasis is the most common form of the disease, affecting 80–90% of patients, characterized by well-demarcated erythematous plaques.2 Psoriasis greatly affects patients’ quality of life (QoL) and psychological wellbeing, and can also be associated with joint disease, cardiovascular disease, inflammatory bowel disease (IBD), and depression. The exact cause of psoriasis is unknown; however, it is widely accepted that affected individuals may have a genetic predisposition involving immune-related genes, the interplay of which leads to a dysregulation of the adaptive and innate immune systems.3,4 The resulting changes in cytokine mediators lead to hyperproliferation and abnormal differentiation of epidermal keratinocytes, lymphocyte infiltration, and vascular changes, manifesting as lesions on the skin.2 Due to the chronic nature of the condition, patients require regular assessments to monitor disease severity and treatment effectiveness. Recently, a European consensus group defined treatment goals for moderate–severe psoriasis. Accordingly, a goal in psoriasis treatment is to reduce cutaneous signs and symptoms by at least 75%, as measured by the Psoriasis Area Severity Index (PASI), and to guarantee a good quality of life (QoL), as measured by a dermatology life quality index (DLQI) score of ≤5.5-7 Topical therapies are suggested for patients with limited disease. If the psoriasis is unresponsive to topical therapies, or if the disease is more extensive, then phototherapy (eg, psoralen ultraviolet A [PUVA], ultraviolet B [UVB]), oral therapies (eg, methotrexate, cyclosporine A, acitretin) or biological therapies (eg, anti-tumor necrosis factor [TNF] drugs) are recommended.2 The introduction of biologic agents has greatly improved disease management in patients with moderate–severe chronic psoriasis.5 While there are numerous biologic agents currently approved for the treatment of moderate–severe plaque psoriasis, in this article we will be proving an in-depth clinical review of originator adalimumab.
Adalimumab Mechanism of Action and Rationale for Use in Psoriasis
Tumor necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, plays an important role in the pathogenesis of psoriasis.8,9 Patients with psoriasis have increased levels of TNF-α in their skin and serum, which significantly correlate with the severity of disease.2 Upon successful treatment of psoriasis, levels of TNF-α are reduced to normal.2 Adalimumab is a recombinant, fully human, monoclonal antibody against TNF-α. It binds with high affinity and specificity to TNF-α and blocks its interaction with both p55 and p75 cell-surface TNF receptors, neutralizing the biological