Although there is an increased risk for infectious and neoplastic events linked to cirrhosis, the safety of biologic therapies in patients with psoriasis and comorbid cirrhosis appears to be reasonable, according to the results of a multicenter, nationwide, retrospective, observational analysis published in the British Journal of Dermatology.

The investigators sought to examine adverse events (AEs) and outcome parameters in a group of patients with psoriasis who were treated with biologics (ie, etanercept, adalimumab, infliximab, and ustekinumab) and had received a diagnosis of cirrhosis (alcoholic or mixed alcoholic; nonalcoholic steatohepatosis) prior to initiating biologic therapy. The presence of cirrhosis was confirmed by a referent hepatologist. Alcohol abuse was defined as the regular consumption of >40 grams of alcohol per day in women and >60 grams of alcohol per day in men.

A total of 23 patients — 4 women and 19 men — were enrolled in the study. Median patient age was 60 (range, 47 to 71), and median delay between cirrhosis diagnosis and initial biologic treatment was 12 months (range, 1 to 153 months). The severity of cirrhosis was usually mild, scored as Child-Pugh A in 91.3% (21 of 23) of participants. Only 39.1% (9 of 23) of patients avoided alcohol consumption during the study period. Overall, fewer than half (43%) of participants had been treated with a single course of systemic therapy prior to the introduction of biologic therapy. In 39% (9 of 23) of patients, a biologic agent was the first systemic therapy ever used.


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In the 23 participants, a total of 33 different courses of biologic agents were identified: etanercept (n=10), ustekinumab (n=10), adalimumab (n=8), and infliximab (n=5). Prior to the initiation of biologic therapy, the median Psoriasis Area and Severity Index score was 27 (range, 12 to 56), and the median Physician Global Assessment (PGA) score was 4 (range, 3 to 5). The median duration of biologic treatment was 31 months (range, 4 to 102 months). Overall, nearly half (11 of 23) of participants were receiving continuous biologic therapy for >2 years.

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During the treatment, 5 patients experienced 6 AEs. One patient who had extensive skin disease and decompensated Child-Pugh cirrhosis died of generalized sepsis of unknown origin. Biologic treatment was resumed in the other four patients after their infections were resolved. Clearing or almost clearing of patients’ psoriasis (PGA score of 0 to 1) was reported in 30.4% of participants at week 16, in 61.9% at week 24, and in 82.3% at 1 year.

The investigators concluded that although the use of biologic therapies in this patient population appeared to be prudent, these agents should be used with caution in such individuals, particularly in patients with decompensated cirrhosis and/or severe liver disease.

Reference

Begon E, Beneton N, Poiraud C, et al. Safety and efficacy of biologic therapies in psoriatic patients with alcoholic cirrhosis: a French retrospective study of 23 cases [published online February 26, 2018]. Br J Dermatol. doi:10.1111/bjd.16490