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Can Biologics Be Combined With Other Treatments
The use of a single drug or a single therapy method may not work for everyone with psoriasis. If single drugs arent working for you, or arent working as well as they once did, it may be time to consider combining biologics with other treatments for psoriasis.
There are three main benefits of using a combination approach:
- It can decrease the possibility of reaching toxic levels with a single drug.
- The individual drugs can be prescribed at a lower dose.
- A combination approach can be more successful than a single treatment option.
Biologics Versus Older Psoriasis Medications
Biologics target specific parts of the immune system that cause inflammation.
Think of the immune system as a line of dominoes. The older drugs take no prisoners, knocking down the entire line. Biologics, on the other hand, start midway through the lineup, blocking inflammation only from that point on.
This is why biologics tend to cause fewer side effects than older drugs, Dr. Hwang explains.
Biologics have been game-changers for many people with psoriasis. It’s now possible to achieve clear skinâwith no plaquesâin weeks. This is much faster than what has been seen with older disease-modifying psoriasis drugs, he says.
They also have a convenience edge.
“You can give yourself injections at home in the fat layer under your skin, similar to insulin injections for people with diabetes,” Dr. Hwang says.
But unlike insulin, these shots aren’t given daily. “Some are only given every 12 weeks,” he says. “This is extremely convenient.”
Your doctor will have to teach you or your caregiver how to self-inject these medications before giving you the green light to do so at home.
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Interleukin 12 And 23 Inhibitor
Stelara selectively targets IL-12 and IL-23, both of which are involved in the inflammation cascade that leads to psoriasis.
It is given by self-injection under the skin initially, again at week four, and then every 12 weeks thereafter. It is also approved to treat psoriatic arthritis, Crohns Disease, and ulcerative colitis.
How Safe Are Biologics
All biologics that treat autoimmune diseases carry the potential for serious side effects. Of the 23 marketed since 1998, 13 got “black box” warnings, the most stringent issued by the U.S. Food and Drug Administration. Two since have been taken off the market. Side effects include serious fungal, bacterial and viral infections, sepsis, various neurological conditions, cancers, suicide and heart and liver failure.
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Starting A Biologic For Psoriasis: What To Expect
- Before starting a biologic drug, you will be screened for infections and baseline monitoring.
- Biologic drugs are taken by injection or IV infusion, and some can be self-injected.
- Doses are often decreased over time.
- Biologic drugs typically take between 10 and 14 weeks to start working.
Starting a biologic drug for psoriasis involves a screening process that considers your medical history and current health condition. Biologics can be highly effective in the treatment of moderate to severe psoriasis, but risk factors need to be assessed before starting biologic therapy.
Biologic drugs work by suppressing overactive proteins in the immune system that cause flare-ups and the overproduction of skin cells. Biologic therapy is considered when topical treatments, corticosteroids, and other treatments such as phototherapy have not been effective. Biologics may also be a treatment option in combination with other therapies or to replace another systemic therapy like cyclosporine.
MyPsoriasisTeam members often ask questions about starting a biologic drug. I just got home from the dermatologist and Im going to be starting a biologic for the first time after blood work is confirmed, a member wrote. Any suggestions for someone whos never used medications like that?
Im starting the new med today! Anyone have any input on their favorite time of day to take a biologic? asked another member.
What Makes Someone A Candidate For Biologics And Who Should Avoid Them
Biologics are appropriate for people with moderate to severe psoriasis. In some cases, this refers to psoriasis that affects more than 10% of the bodys surface area.
People with psoriasis that affects less of the skin may still receive biologics. The affected areas may be unique and significant for example, psoriasis affecting the hands can be debilitating, even though it only covers a small percent of the total body surface area.
People who should not receive biologics include those with active cancer, an active infection , and individuals who are systemically unwell, in general.
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Youd Prefer To Take Fewer Doses
Many psoriasis treatments have to be taken daily to be effective. It can be hard to remember to take your medication on time, especially if youre busy or you travel often. Biologics, on the other hand, are usually taken less frequently.
Some biologics have to be injected once per week, but others like ustekinumab only need to be injected once every 12 weeks after the first two initial doses.
You can also give yourself most biologics at home after being trained by a medical professional.
Differences In Administration Efficacy And Conditions Treated
Biologics are a newer class of drugs used to treat the inflammation that is caused by inflammatory bowel disease . This is a broad range of medications that each work in slightly different ways with different standards of administration and dosing. Some are approved to treat just one form of IBD, while others are used to treat both Crohn’s disease and ulcerative colitis.
Because biologic drugs temper the immune response, people taking them are prone to certain infections. It’s important, therefore, to take steps to reduce your vulnerability. People with IBD should receive vaccinations, ideally before starting a biologic, although many immunizations can also be given while taking a biologic.
According to 2020 guidelines, a biologic drug should be used first-line for treatment in people with moderate to severe ulcerative colitis.
Many factors are taken into consideration when choosing the right biologic. This can include the type and severity of your disease, your treatment history, and your insurance coverage, among other factors. Doctors will take all of these factors into consideration when making a recommendation for treatment.
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Barriers To Widespread Use
When biologics first came on the scene, guidelines called for starting with older and less-expensive disease-modifying drugs, such as methotrexate and cyclosporine, but now doctors are increasingly starting biologics earlier when and where they can.
The main impediment? Cost.
Access to biologics has been impeded by the high costs of these drugs. Some insurers require that you tryand failother therapies before starting on a biologic for your psoriasis. This is known as step therapy, and it is meant to rein in costs.
Access is not bad, says Dr. Strober. However, the prior authorization work needed to deliver the drugs and imposed on a busy practice is onerous.
F Grading The Evidence For Each Key Question
Two reviewers will independently evaluate the strength of evidence for each comparison and outcome deemed most important, and disagreements will be resolved through discussion. Rating of the strength of evidence will be conducted using recommendations from AHRQ.23 This system uses four required domains: risk of bias, consistency, directness, and precision. Additional optional domains will be used if determined appropriate given the identified literature.
| Grade |
|---|
| Evidence either is unavailable or does not permit estimation of an effect. |
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What Precautions Can Patients Take
Because people who use biologics are at higher risk for various infections, they should be tested for tuberculosis and hepatitis B and C before starting on the drugs. They also need to alert their doctor if they have a high fever or if they have a growing infection. Being checked for signs of skin cancer also is a good idea. Patients can receive vaccinations while on the drugs, but not vaccinations that use a live virus such as the MMR vaccine. Avoiding people who are sick and practicing good personal hygiene also are recommended.
What Are Biologics And How Are They Different From Other Treatments For Psoriasis
Biologics are medications that are either made from living cells in a lab or through a biological process. This is how they get their name. Traditional drugs, on the other hand, are small molecules created in a lab.
Biologics target specific parts of the immune system. They treat diseases by modulating activity of specific immune cells or inflammatory messengers called cytokines.
Since biologics are so targeted, they can also be safer than medications that broadly suppress the immune system.
As we continue to gain knowledge about the specific causes of diseases such as psoriasis, better and safer biologics will continue to come onto the market.
Four classes of biologics are currently available:
- blockers of tumor necrosis factor-alpha
- interleukin 12 and 23 inhibitors
- IL-17 inhibitors
- IL-23 inhibitors
Each of these molecules are specific messengers in the immune system involved in the development of psoriasis. The dosing regimen and side effects differ, depending on the drug.
TNF-alpha blockers include adalimumab , etanercept , and certolizumab pegol .
They are all approved to treat both psoriasis and psoriatic arthritis. Depending on the drug, people will need a dose every week or every other week.
Also, these biologics are the most broad-acting medications, as TNF-alpha is an upstream mediator of inflammation. The further downstream the target, the more specific the biologic is, and potentially the fewer side effects it has.
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Dermatologists Walk Through Their Processes
The availability of biologics has radically transformed the treatment for moderate-to-severe psoriasis.
Ever since the first biologic for treating psoriasis in was approved in 2003, researchers have shown that these drugs can effectively and safely treat the disease. In fact, current biologic agents have become so effective — and with favorable safety profiles — that dermatologists increasingly suggest that complete clearance has become a reality for patients with psoriasis.
Today biologics including adalimumab , brodalumab , certolizumab pegol , etanercept , infliximab , guselkumab , ixekizumab , ustekinumab , secukinumab , tidrakizumab have received FDA approval for psoriasis indications, with more applications pending or planned.
“We’re fortunate to have 10 FDA-approved biologics for psoriasis,” said Colby Evans, MD, of Evans Dermatology, Austin, Texas, and former president of the National Psoriasis Foundation. “And they have really revolutionized the care of psoriasis and psoriatic arthritis.”
So, who are candidates for biologic therapy? “You need to assess how severe their psoriasis is, how it’s impacting their lives, and whether they have arthritis, in order to make the decision on what the right treatment is,” said Evans. “But, for the moderate-to-severe patient, and where psoriasis is really interfering with their lives, biologics are certainly in the mix as a good choice.”
What Steps Should Someone Take If A Biologic Is Ineffective Or Stops Working
Many people experience benefits from biologics for several years. But in some cases, the response lessens over time.
This may result from the persons body developing antibodies against the medication, neutralizing its effect. In some cases, a particular class of biologics may not be effective at all.
While psoriasis on any two people may look the same, various genetic mutations can cause the condition. Depending on the particular type of mutation, or genotype, a person may respond better to a certain class of biologic.
Currently, medical professionals have yet to identify all of the genetic mutations that cause psoriasis, and they have no way of predicting which drug will lead to the best response.
However, many of these medications have been evaluated both in people new to biologics and those who have previously used other types. So, we do have some guidance when making decisions for our patients.
If an individual does not respond to a biologic after several weeks of continuous use, or if someone is no longer responding to one, the dermatologist may change the medication to another in the same class or to one in a different class.
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Can Biosimilars Be Used With Other Treatments
It is important to tell your health care provider about all treatments, medicines, vitamins or supplements that you are taking.
Like all biologics, biosimilars can be used with other treatment options including topicals and phototherapy. The biologics Enbrel, Humira and Remicade are shown to be safe and effective when taken with methotrexate. This means that their biosimilars, including Erelzi, Amjevita, and Inflectra, may be safe and effective when taken with methotrexate.
- With Inflectra being the biosimilar to Remicade, its use in combination with phototherapy may increase the risk for skin cancer.
- No drugs that interact with biologics should be combined with their respective biosimilars.
Review Of Key Questions
For all EPC reviews, key questions were reviewed and refined as needed by the EPC with input from Key Informants and the Technical Expert Panel to assure that the questions are specific and explicit about what information is being reviewed. In addition, for Comparative Effectiveness reviews, the key questions were posted for public comment and finalized by the EPC after review of the comments.
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Other Types Of Biologics
Biologics refer to any type of medical treatment that is derived from living organisms. They can include a wide variety of therapeutic options such as blood platelets, hormones, vaccines, and stem cells. Generally, biologic medications for treating autoimmune conditions involve using antibodies to directly target autoimmune processes to decrease inflammation.
Over Time A Biologics Effectiveness Might Diminish
After months or years of taking a certain biologic, it may become less effective for you. Thats because your immune system may develop antibodies to the drug, particularly if you missed any doses. If this happens, you might notice plaques gradually coming back, and your doctor may recommend switching to another biologic.
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Drawbacks Of Biologic Drugs
People who take biologic drugs have an increased risk of infection, Dr. Kimball explained. They’re tweaking with your immune system, she said. We watch for infection, primarily, as the major thing that we’re keeping an eye on.
Biologics are also expensive, said Dr. Kimball. The average cost for biologic drugs is between $10,000 and $30,000 per year. Some insurance plans may cover the cost of biologics, but for some people, the out-of-pocket expense may be prohibitive.
Another drawback is that biologic drug administration requires IV infusion or an injection, which may not appeal to some people with psoriasis. That can be both intimidating and uncomfortable, said Dr. Kimball.
What Are The Potential Side Effects Of Biologics And How Can Someone Manage Them
The main side effects that biologics can cause include infections and malignancies.
While reducing inflammation in the skin is good for psoriasis, blocking the immune system which defends the body from infections and combats cancerous cells can potentially lead to adverse effects.
If the immune system does not protect the body from infections and cannot recognize and fight off abnormal cells as well as usual, a person may have a greater risk of infections and malignancies.
Besides these risks, TNF blockers have been associated with the development of multiple sclerosis, or MS.
Also, IL-17 blockers have an additional warning about a potential increased risk of inflammatory bowel disease, or IBD.
While the potential adverse effects may be worrisome, they are extremely rare. With regular follow-up visits to a dermatologist, these drugs are safe to use.
The dermatologist will examine the persons skin, assess their medical history for any potentially concerning symptoms, and perform blood monitoring.
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Biologic Treatments Used In Dermatology
Biologics are medications made from human or animal proteins. They are designed to specifically target biologic pathways that cause inflammation in the skin and other organs.
Biologics have been used in many people worldwide to treat severe psoriasis, psoriatic arthritis, other types of arthritis and inflammatory bowel diseases . Biologic medications are given as injections.
A condition such as psoriasis develops in people who are genetically predisposed. Immune cells are triggered and become overactive, creating inflammation in the skin and, in some cases, the joints . Biologics work in different ways to traditional treatments by blocking the activation and behaviour of immune cells that play a role in a disease such as psoriasis. Examples of biologic drugs currently used in Australia to treat psoriasis include etanercept , adalimumab , infliximab , ustekinumab and secukinumab .
It is important to remember that all systemic medications, whether traditional or the newer biologics, have broad effects and people undergoing treatment have to be carefully monitored.
Biologics are very expensive. In Australia they are available on the Pharmaceutical Benefits Scheme only after all the more commonly prescribed treatments have been tried and shown to be ineffective or cannot be used in in a particular person due to side effects.
This information has been written by Dr Pam Brown
Vaccinations And Biological Agents
Immunisation status should be reviewed prior to starting treatment with biological agents. If necessary, vaccines should be updated prior to treatment. Annual influenza vaccination is recommended.
As they may induce illness in immunodeficient individuals, live vaccines should not be used during treatment with biological agents. Currently-available live attenuated viral vaccines include measles, mumps, rubella, varicella, yellow fever, the intranasal form of influenza vaccine, and the oral polio vaccine. Live attenuated bacterial vaccines include BCG and oral typhoid vaccine.
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