Dose Loading and Long-Term Treatment Outcomes in Psoriasis

A review of literature found that loading doses had little effect on overall success rates but had substantial value for patients with psoriasis by improving short-term outcomes, according to results of a study presented at the 2022 Annual Meeting of the American Academy of Dermatology (AAD), held from March 25 to 29, 2022 in Boston, Massachusetts.

Biologic therapies are used for treating inflammatory diseases and often include a loading dose. The justification for administering a loading dose include shortening the time to clinical response or reaching therapeutic drug levels and neutralizing anti-drug antibodies. However, dosing recommendations do not seem to have a clear pattern about why a loading dose is recommended and, administering these higher doses increases treatment cost.

Despite the recommended practice to administer a loading dose in some cases, there have been few studies which compare clinical outcomes among patients who did and did not receive a loading dose. In order to evaluate current evidence of the effect of loading doses, investigators from Beth Israel Deaconess Medical Center performed a literature review for evidence about loading doses in psoriasis. In addition, the investigators assessed dosing recommendations for various inflammatory diseases.

The review authors identified 254 studies which examined the clinical outcomes of systemic therapy for psoriasis, among which only 5 studies included head-to-head data evaluating the effect of a loading dose.

The 5 head-to-head trials included adalimumab, etanercept, or secukinumab as the active treatments. The studies found that loading doses had more favorable short-term outcomes but had little impact on long-term clinical outcomes. A study presented evidence that clinical response was commensurate with total drug received after week 4 and another study observed that clinical response was no difference between groups from week 12.

In general, therapies approved for the treatment of inflammatory diseases are administered with a 12-week loading dose followed by the maintenance dosing. Stratified by disease, nonradiographic axial spondyloarthritis is recommended to receive the lowest loading and maintenance dosing; ankylosing spondylarthritis, rheumatoid arthritis, and psoriatic arthritis to receive low loading doses and high maintenance doses; ulcerative colitis and Crohn disease are treated with high loading doses and low maintenance doses; and uveitis, psoriasis, and hidradenitis suppurativa to receive both high loading and maintenance dosing.

This review found that regimens for inflammatory dermatologic disorders are administered at higher dosage than other inflammatory diseases.

There remains a paucity of data which shows the efficacy of administering high loading doses, the researchers maintain. They believe that the current evidence supports that loading doses may improve short-term outcomes but likely has little effect on overall clinical outcomes. Additional study of the efficacy of loading doses is need.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Greif C, Gibson R, Porter M, Kimball A. Do loading doses in systemic therapy for psoriasis improve clinical outcomes? Presented at: the AAD 2022 Annual Meeting; March 25-29, 2022. Abstract/Poster 33121.