Successful Treatment of Refractory Plaque-Type Psoriasis and Psoriatic Arthritis With Guselkumab and Adalimumab Combination Therapy: A Case Report
April 2019 | Volume 18 | Issue 4 | Case Reports | 394 | Copyright © April 2019
Dipali Rathod DNB DDVL,a Jeffrey M. Weinberg MD,b Paul S. Yamauchi MD,c Leon H. Kircik MD,d Uwe Wollina MD,e Torello Lotti MD,f Mohamad Goldust MDg
aMumbai, Maharashtra, India bIcahn School of Medicine at Mount Sinai, New York, NY cDermatology Institute and Skin Care Center, Santa Monica, CA; Division of Dermatology, David Geffen School of Medicine at University of California, Los Angeles, CA dIcahn School of Medicine at Mount Sinai, New York, NY eDepartment of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany fUniversity of Studies Guglielmo Marconi, Rome, Italy gMazandaran University of Medical Sciences, Sari, Iran
No serious adverse effects were observed on follow up after 6 months with the combination therapy. She stated that she never felt symptomatically better and insisted on maintaining the 2-biologic regimen, but the physician discontinued adalimumab due to possible adverse effects of combination biologic therapy and continued only guselkumab every 8 weeks for the patient.
An armamentarium of treatment options available for advanced plaque psoriasis includes NBUVB phototherapy, psoralen with ultraviolet A light (PUVA), retinoids, methotrexate (particularly for arthritis), cyclosporine, and biological agents.7,8 Few of the previous studies regard biological agents as third-line treatment for plaque psoriasis following inadequate response to topical treatment, phototherapy, and non-biologic systemic medications. Individuals with psoriasis may develop neutralizing antibodies against monoclonal antibody medications, thereby decreasing the effectiveness of these medications.9,10 Our patient, receiving combination treatment with adalimumab and guselkumab experienced a great reduction in both the signs and symptoms of the psoriatic disease without any adverse effect during therapy. The combination biologic therapy or treatment with guselkumab alone was found to achieve PASI 90 in most patients when administered as a monotherapy.11 Babino et al evaluated the combination therapy with etanercept in psoriasis and demonstrated that short-term co-medication in combination with etanercept may optimize treatment options and improve long-term survival in patients with psoriasis.12 However, it was not the same in the study conducted by Bruzzese et al, who evaluated new onset or worsening of the disease following biologic therapy. Six patients were receiving a biologic monotherapy, while four patients were in combination treatment with MTX. Psoriasis remission was observed in two patients who discontinued biologic therapy. In the six patients in whom biologic therapy was not discontinued, a complete disappearance or a partial improvement of skin lesions was achieved following topical steroid therapy in two patients and three patients, respectively. In the remaining patient, psoriasis developed during adalimumab monotherapy, which completely disappeared when the infliximab and MTX combination was started.13 Babalola et al14 demonstrated a great reduction in both the signs and symptoms of psoriatic disease with concomitant ustekinumab and etanercept treatment and further stated that ustekinumab effectively cleared skin lesions, whereas etanercept treated the symptoms of psoriatic arthritis, but we could not demonstrate any relationship between the type of biologic agent and psoriatic disease. Their case experienced a cardiovascular event, which they proposed that it could not be definitively attributed to the therapies in contrast to our case, where no major side effects were observed. The question of the cost-effectiveness of biologic agents versus pharmacotherapy has not been resolved to date. The past few years has been marked by the introduction of new biologic agents for the induction and maintenance of response in patients with psoriasis. Although widely heralded for their efficacy, these agents have also stirred controversy over the potential economic impact that they will have upon the world's health-care systems.15 Previous studies have shown that the cost of psoriasis medication contributed minimally towards the overall cost associated with the disease; however, these studies were all conducted before the introduction of biologic therapies. Incorporation of data on indirect cost-savings and quality of life improvements into ongoing and future analyses is required to allow for more accurate analyses of overall costs and cost-savings.16 Cost-effectiveness information on biologic use can assist decision makers in evaluating the overall value of a new treatment or new technology.17
Poorly controlled, therapy-resistant psoriasis negatively impacts quality of life and health care costs. Medication adherence, socioeconomics, and other factors complicate biologic treatments in psoriasis. There is limited data on combination of biological agents in the management of psoriasis and psoriatic arthritis. In patients who do not respond to multiple approaches for the treatment of psoriasis, combination therapy with biological agents may lead to dramatic disease control; however, combination of biologic agents is not considered standard of care in dermatology for safety reasons and currently not recommended. The risk and benefits of combination therapy needs to be carefully examined and further larger studies need to be conducted to establish safety and validate the findings.
Paul S. Yamauchi: Investigator, consultant, and speaker for Amgen, Abbvie, Janssen, Lilly, Novartis, Ortho Dermatologics, Sun Pharma and UCB.The remaining authors have reported no conflicts.
- Kavanaugh A, Ritchlin C, Rahman P et al. Ustekinumab, an anti-IL-12/23 p40 monoclonal antibody, inhibits radiographic progression in patients with active psoriatic arthritis: results of an integrated analysis of radiographic data from the phase 3, multicentre, randomised, double-blind, placebo-controlled PSUMMIT-1 and PSUMMIT-2 trials. Ann Rheum Dis. 2014; 73(6):1000-6.
- Soriano ER, Marin J, Acosta-Felquer ML. Psoriatic arthritis: new evidence for old concepts. Curr Opin Rheumatol. 2018; 30(1):87-93.
- Armstrong AW, Bagel J, Van Voorhees AS et al. Combining Biologic Therapies With Other Systemic Treatments in Psoriasis: Evidence-Based, Best- Practice Recommendations From the Medical Board of the National Psoriasis Foundation. JAMA Dermatol. 2015; 151(4):432-8.
- Belinchon I, Arribas MP, Soro P et al. Recovery of the response to biological treatments using narrow band ultraviolet-B in patients with moderate to severe psoriasis: a retrospective study of 17 patients. Photodermatol Photoimmunol Photomed. 2014; 30(6):316-22.
- Chlapanida s T, Perteghella S, Leoni F et al. TNF-alpha blocker effect of naringenin-loaded sericin microparticles that are potentially useful in the treatment of psoriasis. Int J Mol Sci. 2014 6;15(8):13624-36.
- Kopylov U, Afif W, Cohen A et al. Subcutaneous ustekinumab for the treatment of anti-TNF resistant Crohn's disease--the McGill experience. J Crohns Colitis. 2014; 8(11):1516-22.
- Kaser A. Not all monoclonals are created equal - lessons from failed drug trials in Crohn's disease. Best Pract Res Clin Gastroenterol. 2014; 28(3):437-49.
- Smilek DE, Ehlers MR, Nepom GT. Restoring the balance: immunotherapeutic combinations for autoimmune disease. Dis Model Mech. 2014 May;7 (5):503-13.
- Wilsmann-Theis D, Fronhoffs K, Ehler LK, Wenzel J, Bieber T, Klingmueller K. Low-dose methotrexate - a therapeutical kick in TNF-alpha antagonist treatment for recalcitrant psoriasis vulgaris. Dermatol Ther. 2014; 27(1):55-59.
- Ritchlin C, Rahman P, Kavanaugh A, McInnes IB, Puig L, Li S et al. Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial. Ann Rheum Dis. 2014; 73(6):990-999.
- Al-Salama ZT, Scott LJ. Guselkumab: A Review in Moderate to Severe Plaque Psoriasis. Am J Clin Dermatol. 2018 Dec;19(6):907-918.
- Babino G, Giunta A, Ruzzetti M, Sole Chimenti M, Chimenti S, Esposito M. Combination therapy with etanercept in psoriasis: Retrospective analysis of efficacy and safety outcomes from real-life practice. J Int Med Res. 2016 Sep;44(1 suppl):100-105.
- Bruzzese V, De F, V, Hassan C, Lorenzetti R, Scolieri P, Marrese C et al. New onset or worsening of psoriasis following biologic therapy: A case series. Int J Immunopathol Pharmacol. 2017 Mar 1930;70-72.
- Babalola O, Lakdawala N, Strober BE. Combined biologic therapy for the treatment of psoriasis and psoriatic arthritis: A case report. JAAD Case Rep. 2014 19;1(1):3-4.
- Palmer JB, Li Y, Herrera V et al. Treatment patterns and costs for anti-TNFα biologic therapy in patients with psoriatic arthritis. BMC Musculoskelet Disord. 2016 14;17:261.
- Cohen RD. The pharmacoeconomics of biologic therapy for IBD. Nat Rev Gastroenterol Hepatol. 2010 Feb;7(2):103-9.
- Bukstein DA, Luskin AT. Pharmacoeconomics of biologic therapy. Immunol Allergy Clin North Am. 2017;37(2):413-430.