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Psoriasis (cont.)

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What injections or infusions are available for psoriasis?

The newest category of psoriasis drugs are called biologics, because they are produced by living cells. They are all proteins and therefore must be administered through the skin. All biologics work by suppressing certain specific portions of the immune inflammatory response that are overactive in psoriasis. Available biologic drugs include adalimumab (Humira), infliximab (Remicade), etanercept (Enbrel), ustekinumab (Stelara), secukinumab (Cosentyx), and ixekizumab (Taltz). Newer drugs are in development and no doubt will be available in the near future. As this class of drugs is fairly new, ongoing monitoring and adverse effect reporting continues and long-term safety continues to be monitored. Biologics are all comparatively expensive especially in view of the fact they none of them are curative. Recently, the FDA has attempted to address this problem by permitting the use of "biosimilar" drugs. These drugs are structurally identical to a specific biologic drug and are presumed to produce identical therapeutic responses in human beings to the original, but are produced using different methodology. Biosimilars ought to be available at some fraction of the cost of the original. If this will be an effective approach remains to be seen. The only biosimilar available currently is infliximab (Inflectra). Two other biosimilar drugs have been accepted by the FDA, an etanercept equivalent (Erelzi) and an adalimumab equivalent (Amjevita) -- but currently, neither are available.

Some biologics are to be administered by self-injections for home use while others are given by intravenous infusions in the doctor's office. Biologics have some screening requirements such as a tuberculosis screening test (TB skin test or PPD test) and other labs prior to starting therapy. As with any drug, side effects are possible with all biologic drugs. Common potential side effects include mild local injection-site reactions (redness and tenderness). There is concern of serious infections and potential malignancy with nearly all biologic drugs. Precautions include patients with known or suspected hepatitis B infection, active tuberculosis, and possibly HIV/AIDS. As a general consideration, these drugs may not be an ideal choice for patients with a history of cancer and patients actively undergoing cancer therapy. In particular, there may be an increased association of lymphoma in patients taking a biologic.

Biologics are expensive medications ranging in price from several to tens of thousands of dollars per year per person. Their use may be limited by availability, cost, and insurance approval. Not all insurance drug plans may fully cover these drugs for all conditions. Patients need to check with their insurance and may require a prior authorization request for coverage approval. Some of the biologic manufacturers have patient-assistance programs to help with financial issues. Therefore, choice of the right medication for your condition depends on many factors, not all of them medical. Additionally, convenience of receiving the medication and lifestyle may the choice of the right biologic medication.

Currently, the main classes of biologic drugs for psoriasis are

  1. TNF (tumor necrosis factor) blockers,
  2. drugs that interfere with interleukin chemical messengers of inflammation.

TNF blockers

TNF blockers include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira). TNF-alpha blocking drugs may have an advantage of treating psoriatic arthritis and psoriasis skin disease. Their disadvantage is that some patients may notice a decrease in the effectiveness of TNF-alpha blocking drugs over months to years.

TNF blockers are generally not used in patients with demyelinating (neurological) diseases like multiple sclerosis, congestive heart failure, or patients with severe overall low blood counts called pancytopenia.

The major side effect of this class of drugs is suppression of the immune system. Because of the increased risk of infections while on these drugs, patients should promptly report fevers or signs of infection to their health care providers. Other side effects have included autoimmune conditions like lupus or flares in lupus. Additionally, it is best to avoid any live vaccines while using TNF blockers.

  • Etanercept is a self-injectable medication for home use. It is injected via a small needle just under the skin, called subcutaneous injection. It is usually dosed once or twice weekly by patients at home after training with their physician or the nursing staff. Sometimes a higher loading dose is used for the first 12 weeks and then it is "stepped down" to half the dose after the first 12 weeks.
  • Infliximab is an intravenous (IV) medication strictly for physician office or special infusion medical center use. It is dosed specifically based on the patient's weight. It is currently not for home use or self-injection. It is infused slowly over time via a small needle into a vein. After a six-week loading period, it is infused every two months. There have been reports of antibodies to this drug in patients taking it for some time. These antibodies may cause a greater drug-dose requirement for achieving disease improvement or failure to improve. The IV route may be more time-consuming, requiring physician during the infusions. Remicade has the advantage of fast disease response, dependable dosing, and good potency.
  • Adalimumab is a self-injectable medication for home use. It is injected via a small needle just under the skin as a subcutaneous dose. It is usually dosed once every other week, totaling 26 injections in one year. Dosing is individualized and should be discussed with a physician. Sometimes a higher loading dose is used for the first dose (80 mg) and then it is continued at 40 mg every other week. It may give results as soon as one to two weeks of therapy.

Drugs that interfere with interleukin mechanisms

  • Ustekinumab is a biologic injectable medication used to modulate the immune system. It is an interleukin-12/23 human monoclonal antibody. Ustekinumab targets chemical messengers in the immune system involved in skin inflammation and skin-cell production. This drug is dosed subcutaneously (just under the skin) once a quarter (every three months). It has been very promising with very good clearance rates in the clinical trials. A major advantage may be the convenience of a quarterly medication. The concerns for infection and malignancy may be similar to the other biologics.
  • Secukinumab interferes with interleukin 17 and produces a high rate of clearance and is given monthly after a weekly induction period.
  • Ixekizumab also interferes with the interleukin 17 pathway and produces a high rate of clearance and is given monthly after an induction period.
Medically Reviewed by a Doctor on 3/23/2017


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