Previous History of Failed Biologics Associated With Greater Switching in Psoriasis

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Higher baseline-PASI and number of previous failed biologic therapies were associated with a greater need for switching in psoriasis.

Individuals with psoriasis who have a history of failed biologics and higher baseline Psoriasis Area and Severity Index (PASI) scores are more likely to switch biologics, according to a study recently published in the Journal of the American Academy of Dermatology. Longer drug survival should be prioritized in clinical practice and is best achieved by switching between biologic classes vs within, and by doing so only when necessary.

This retrospective study included 195 individuals (65.6% men) with moderate-to-severe psoriasis who were treated in an Italian hospital between 2006 and 2018. Treatment effectiveness was defined as achieving and maintaining a PASI score of 75 within 4 months. Otherwise, the biologic was deemed ineffective and was switched. Primary ineffectiveness in a biologic was defined as not working at all; secondary ineffectiveness was defined as initial success with declining efficacy over time. Drug survival was estimated and compared using Cox models and Kaplan-Meier survival curves. Logistic regression models were employed along with descriptive statistical analyses.

PASI 75 was achieved in 90.6% of participants, PASI 90 in 72.6%, and PASI 100 in 68.4%. In 2018, ustekinumab was the most frequently prescribed biologic in this cohort, used by 27.8% (n=47) of participants. Of the 195 participants, 107 switched at least once: 63 switched once, 24 switched twice, and 20 switched 3 times or more.

Common causes for switching were, in descending order, secondary ineffectiveness, withdrawal of the biologic from the market, and primary ineffectiveness. Switching was 1.08 times more likely among participants with higher PASI at baseline (P =.0399). Ustekinumab had a longer survival rate in those who were biologic-naïve (>7.0 years). Participants with a history of biologic use were 1.20 times more likely to require a switch (P =.014) and did not show significant variance in drug survival. Those who switched between biologic classes had longer drug survival rates than those who switched within classes (hazard ratio, 0.48; P =.003).

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Study limitations include the single-center retrospective design and no evaluation of the relationship between drug survival and antidrug antibodies.

The study researchers concluded that “switching biologics is not unusual in routine practice. Higher baseline PASI and a greater number of previous failed biologic therapies were associated with a higher need for switching. Ustekinumab shows longer drug survival in biologic naïve patients, but it lost this advantage in biologic-experienced patients. We suggest avoiding frequent, unnecessary switches, and when switching is needed, we recommend switching between biologic classes rather than switching within biologic classes in order to obtain longer drug survival. The present study could be a useful starting point for developing better biologics switching protocols for the treatment of psoriasis in the future.”

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Cozzani E, Wei Y, Burlando M, Signori A, Parodi A. Serial biologic therapies in psoriasis patients: a 12-year single-center retrospective observational study [published online May 28, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.05.064