Management of Residual Psoriasis in Patients on Biologic Treatment

February 2020 | Volume 19 | Issue 2 | Original Article | 188 | Copyright © February 2020


Published online January 17, 2020

Wasim Haidari , Adrian Pona , Steven R. Feldman

aCenter for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC bDepartment of Pathology, Wake Forest School of Medicine, Winston-Salem, NC cDepartment of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC

Abstract
While biologics are highly effective, most psoriasis patients do not achieve complete skin clearance with their biologic monotherapy. How to achieve complete skin clearance in psoriasis patients who fail their biologic is not well characterized. To describe treatment approaches in psoriasis patients who fail to achieve complete clearance from their biologic, we modeled and assessed the efficacy, cost, and safety of three treatment approaches– adding a topical agent with their biologic, escalating the biologic dose, and switching to a different biologic. Efficacy of each approach was obtained from literature identifying complete clearance defined as 100% improvement in Psoriasis Area and Severity Index and/or Physician’s Global Assessment score of clear. Cost of each treatment approach was calculated using medication wholesale acquisition cost obtained from Medi-Span Price Rx. Safety was assessed by adverse event (AE) rates. Complete clearance in patients not cleared on their initial biologic was achieved when adding calcipotriene/betamethasone dipropionate (Cal/BD) foam (28%), switching to guselkumab (20%), and switching to infliximab (15.8%). Adding Cal/BD foam to the initial biologic ($3,780 per additional patient cleared) was a less costly approach compared to the lowest cost dose escalation (guselkumab; $73,370 per additional patient cleared) or switching the initial failed biologic to the lowest cost alternative biologic (infliximab; $88,250 per additional patient cleared). There were no treatment-related or serious AEs when adding Cal/BD foam. Adding a topical agent may be an efficacious, low cost, and safe approach to achieve complete clearing in psoriasis patients who previously failed to clear on their biologic.

J Drugs Dermatol. 2020;19(2)188-194 doi:10.36849/JDD.2020.3989

INTRODUCTION

Psoriasis impacts patients’ quality of life as much as other major chronic diseases, including cancer.1,2 Advancements in the treatment of psoriasis, particularly biologics, have allowed for better symptom control, reduction of adverse effects, and improved patient satisfaction, albeit at higher cost.3 Biologic therapies have increased the ability of psoriasis patients to achieve complete skin clearance.5 However, some patients may fail to respond to their biologic agent, and most do not achieve complete clearance.4,11-14 Complete psoriasis clearing is desirable as complete clearance is associated with fewer symptoms and better quality of life compared to less than complete psoriasis clearing.5

There is no clear consensus about how to treat patients who fail to achieve complete clearing with a biologic. Treatment approaches include adding a topical agent, escalating the dose of biologic, or switching to a different biologic. We characterized the different treatment approaches for patients with psoriasis who improve but do not clear with their biologic treatment; we assessed efficacy, cost, and safety of each treatment approach using a model informed by the available literature.

METHODS

A systematic literature review was performed using MEDLINE to find articles discussing treatment approaches for moderate-to-severe plaque psoriasis patients who fail to achieve complete skin clearance on their biologic. Articles describing total psoriasis clearance, defined as 100% improvement in Psoriasis Area and Severity Index (PASI 100) and/or Physician’s Global Assessment score of 0 (PGA 0), were considered. We then characterized the efficacy, cost, and safety of each approach to manage residual psoriasis in patients who failed to achieve complete psoriasis clearing on their biologic.

Efficacy
Efficacy for adding a topical agent as an adjunct was obtained from a published report.17 We did not identify a similar report describing the efficacy of escalating the dose of a biologic in psoriasis subjects who previously failed to achieve complete skin clearance. However, since 18.6% of psoriasis subjects receiving ustekinumab 45 mg were able to achieve PASI 100 and 29.5% of psoriasis subjects were able to achieve PASI 100 on 90 mg of ustekinumab, we estimated that an additional 10.9% of psoriasis subjects would achieve PASI 100 on ustekinumab 90