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Posted By: Lakshi M. Aldredge, MSN, ANP-BC, DCNP
February 21, 2020
These days, it seems that most of us can't avoid seeing a commercial for a psoriasis medication when watching our favorite shows. Most of the ads seem to promise "clear to near-clear skin" with the use of these medications. This promise is then followed by a litany of horrible side effects that no reasonable person would consider when selecting a medication to treat themselves or a loved one who suffers with psoriasis. So, what’s the real "lowdown" on the safety of biologic therapy in psoriasis?
The bottom line is that based on phase three clinical trial data and real-world experience, the newer biologic agents for psoriasis appear to be very safe. The older tumor necrosis factor alpha (TNF-α) agents Cimzia, Enbrel, Humira, and Remicade are very effective in providing significant skin clearance, but do carry risks of infection, malignancy, new onset or worsening heart failure, and demyelinating conditions. These risks tend to be low, but they are still a legitimate concern.
The next-generation biologic agent Stelara is an interleukin (IL)-12/23 antagonist that provides a safe profile with a low risk of infection and even better skin clearance than most of the TNF-α agents. The IL-17 antagonists—Cosentyx, Siliq, and Talz—provide very effective skin clearance but carry a risk of new onset or worsening GI conditions, such as irritable bowel or Crohn's disease, as well as increased risk of fungal infections. Additionally, Siliq carries a warning of increased risk of depression and suicidal ideation and requires enrollment in an online, national monitoring program. Nevertheless, the risks associated with the IL-17 inhibitors are generally low, and many patients continue to have excellent skin improvement with their long-term use.
The newest biologics are the IL-23 inhibitors—Ilumya, Skyrizi, Tremfya. These agents have demonstrated some of the highest levels of skin clearance with excellent safety profiles. In fact, in clinical trials, the risks of infection, mood changes, malignancy, and GI side effects are comparable to placebo. Because these are the newest agents (approved within the last 3 years), longer "real world" data will help confirm their promising safety profiles.
What does this mean for you, as a practitioner? When assessing your patients with psoriasis, it is important to obtain a thorough medical history—specifically asking about a history or infections, malignancies, depression and suicidality, and GI conditions. This can enable you to have a fair and honest discussion with your patients about the myriad of agents available for the treatment of psoriasis and their safety profiles. Carefully weigh your own, and your patient's, concerns about potential side effects against the benefits of appropriately treating their moderate to severe psoriasis. Psoriasis not only affects the skin, but nearly every organ in the body. Patients with psoriasis are at higher risk of developing psoriatic arthritis (leading to permanent joint damage and dysfunction), metabolic syndrome, cardiovascular disease (including increased risk of myocardial infarction and cerebrovascular accidents), non-alcoholic liver disease, chronic renal disease, depression, and anxiety. Through selection of the correct psoriasis medication and appropriate monitoring, your patients with psoriasis can achieve clear skin safely, prevent associated comorbidities, and live healthy and happy lives.
- Armstrong A, Aldredge L, Yamauchi P. Managing patients with psoriasis in the busy clinic: Practical tips for health care practitioners. Journal of Cutaneous Medicine and Surgery. 2016;20:196-206.
- Elmets CA, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. Journal of the American Academy of Dermatology. 2019;80:1073-1113.
- Martin G, Young M, Aldredge L. Recommendations for initiating systemic therapy in patients with psoriasis. The Journal of Clinical and Aesthetic Dermatology. 2019;12:13-26.
- Menter A, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. Journal of the American Academy of Dermatology. 2019;80:1029-1072.
- Young M, Aldredge L, Parker P. Psoriasis for the primary care practitioner. Journal of the American Association of Nurse Practitioners. 2016;29:157-178.
Filed under: Dermatology