An alternative for patients who have not achieved complete clearing with biologic monotherapy may be to add a topical agent. Adding topical agents as an adjunct to biologics can improve clinical response in psoriasis patients who did not achieve complete clearance.18 When comparing all treatment options for patients with psoriasis who failed to achieve complete clearance after their initial biologic, adding Cal/BD foam is the least-costly approach to achieve clearing of residual psoriasis in patients on biologic treatment and was considerably less costly 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; $88,225 per additional patient cleared). Patients may be hesitant to use a topical as they have often failed topicals before going on biologics. However, adding a topical with the best patient friendly properties (once daily, fast acting, effective treatment) will increase chances that the patient will adhere to the treatment. Based on the available evidence, adding a topical to a biologic can provide for complete clearing and may be a safe and lower cost alternative in managing patients with psoriasis who failed to achieve complete clearance from their initial biologic. Dose escalation may assist in clearing a patient’s residual psoriasis.
Dose escalation for a biologic includes shortening of the dosing interval and/or increasing the medication dose per single administration. Dose escalation, although perhaps the simplest strategy, creates an economic burden as doubling the dosage likely doubles the cost.8 Dose escalation approach to achieve clearance in one additional patient is more costly than switching to another biologic or adding a topical (Figure 5). Although we were able to estimate the successful clearance of residual psoriasis by dose escalating a biologic, our estimate was based on an assumption, as there were no studies evaluating dose escalation in patient population failing initial biologic. Our estimation was a reasonably conservative approach because clinical trials try to identify the effective dose.
If patients with psoriasis fail to achieve complete skin clearance from their initial biologic, they may switch to a different biologic.7,10 Switching to another biologic agent can be effective for patients who have failed the first biologic.7,10 Lack of efficacy of a specific biologic may not necessarily equate to resistance to other biologics (Table 1).4 When clearing one additional patient, switching to guselkumab ($108,590 per additional patient cleared) is $20,365 more costly biologic to substitute than switching to infliximab ($88,225 per additional patient cleared) after an initial failed biologic. However, previous failed therapy in those switched to infliximab (etanercept) was different than previous failed biologic in those switched to guselkumab (ustekinumab). When you have a patient who has improved considerably, you know they are not a complete treatment failure. Switching does not guarantee better outcomes; some patients could experience worsening of their psoriasis or no improvement. Other potential problems associated with switching include the economic burden on a patient, the time to achieve complete clearance once initiated on a new biologic, and the length of time for a patient’s