Cosentyx (Secukinumab): Recommended Use and Dosage

Overview

Cosentyx (secukinumab) is a fully human monoclonal antibody targeting interleukin-17A, approved for multiple inflammatory conditions including moderate-to-severe plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, enthesitis-related arthritis, juvenile psoriatic arthritis, and hidradenitis suppurativa. 1, 2

Approved Indications and Dosing Regimens

Plaque Psoriasis (Adults)

Standard dosing: 300 mg subcutaneously at weeks 0,1,2,3, and 4, followed by 300 mg every 4 weeks 1, 2
Alternative dosing: 150 mg may be acceptable for some patients, though 300 mg demonstrates superior efficacy 1
For patients ≥90 kg: Consider 300 mg every 2 weeks for maintenance if inadequate response to monthly dosing 1
Each 300 mg dose is administered as one 300 mg injection or two 150 mg injections 1, 2

The 300 mg dose is strongly recommended over 150 mg based on Level I-II evidence showing significantly greater efficacy with comparable safety. 1

Plaque Psoriasis (Pediatric ≥6 Years)

Weight-based dosing at weeks 0,1,2,3, and 4, then every 4 weeks: 1, 2
- <50 kg: 75 mg
- ≥50 kg: 150 mg

Psoriatic Arthritis (Adults)

For patients with coexistent moderate-to-severe plaque psoriasis: Use the adult plaque psoriasis dosing (300 mg regimen) 1, 2

For other adult PsA patients: 1, 2

With loading: 150 mg at weeks 0,1,2,3, and 4, then every 4 weeks
Without loading: 150 mg every 4 weeks
Dose escalation: If inadequate response, increase to 300 mg every 4 weeks 1, 2
For anti-TNFα inadequate responders: 300 mg is the recommended dose 1

Intravenous option available: 6 mg/kg loading dose at week 0, followed by 1.75 mg/kg every 4 weeks (maximum 300 mg per infusion) 2

Juvenile Psoriatic Arthritis (≥2 Years)

Weight-based dosing at weeks 0,1,2,3, and 4, then every 4 weeks: 1, 2
- ≥15 kg and <50 kg: 75 mg
- ≥50 kg: 150 mg
May be used with or without methotrexate 2

Ankylosing Spondylitis (Adults)

With loading: 150 mg at weeks 0,1,2,3, and 4, then every 4 weeks 1, 2
Without loading: 150 mg every 4 weeks 1, 2
Dose escalation: If inadequate response, increase to 300 mg every 4 weeks 1, 2
Intravenous option: 6 mg/kg loading dose at week 0, followed by 1.75 mg/kg every 4 weeks (maximum 300 mg per infusion) 2

Non-Radiographic Axial Spondyloarthritis (Adults)

With loading: 150 mg at weeks 0,1,2,3, and 4, then every 4 weeks 1, 2
Without loading: 150 mg every 4 weeks 1, 2
Intravenous option: 6 mg/kg loading dose at week 0, followed by 1.75 mg/kg every 4 weeks (maximum 300 mg per infusion) 2

Enthesitis-Related Arthritis (≥4 Years)

Weight-based dosing at weeks 0,1,2,3, and 4, then every 4 weeks: 1, 2
- ≥15 kg and <50 kg: 75 mg
- ≥50 kg: 150 mg

Hidradenitis Suppurativa (Adults)

Standard dosing: 300 mg at weeks 0,1,2,3, and 4, then every 4 weeks 1, 3, 2
Dose escalation: If inadequate response, increase to 300 mg every 2 weeks 1, 3, 2
Each 300 mg dose is given as one 300 mg injection or two 150 mg injections 1, 2

Special Populations and Considerations

Specific Psoriasis Subtypes

Scalp psoriasis: Secukinumab is recommended with Level II evidence 1
Nail psoriasis: Strongly recommended with Level I evidence 1
Palmoplantar plaque psoriasis: Strongly recommended with Level I evidence 1
Palmoplantar pustulosis: Can be recommended with Level B evidence 1
Erythrodermic psoriasis: May be used with Level III evidence 1

Treatment Duration and Discontinuation

Consider discontinuation if no response after 16 weeks of treatment 1
Continuous every 4-week dosing is more effective than as-needed dosing after the initial 12-week course 1
Long-term efficacy and safety demonstrated up to 5 years in plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis 4

Contraindications

Absolute Contraindications

Hypersensitivity to secukinumab or any excipients 1
Clinically important, active infection 1
Active tuberculosis 1

Relative Contraindications and Warnings

Inflammatory bowel disease: Secukinumab is not recommended in patients with inflammatory bowel disease; new cases or exacerbations have been reported and the drug should be discontinued if this occurs 1, 3
Chronic or recurrent infections: Use with caution 1
Latent tuberculosis: Consider anti-tuberculosis therapy before starting secukinumab 1, 5

Pre-Treatment Screening and Monitoring

Baseline Evaluation

Tuberculosis screening (PPD or IGRA) is required before initiating therapy 5, 3
Complete blood count (CBC) to monitor for potential neutropenia 5
Inflammatory markers (CRP) should be considered at baseline to assess disease activity 5
Assess for inflammatory bowel disease history as this is a contraindication 1, 3
Complete age-appropriate vaccinations before starting treatment 2

Ongoing Monitoring

Periodic CBC monitoring during maintenance therapy to identify neutropenia 5
Clinical monitoring for signs of infection is essential, as secukinumab increases infection risk 5
Monitor for inflammatory bowel disease markers in patients with risk factors 5

Safety Profile and Adverse Events

Common Adverse Events (≥1/10)

Upper respiratory tract infections 5, 3
Oral herpes 3
Headache 3
Rhinorrhea 3
Diarrhea 3
Nausea 3
Fatigue 3

Serious Adverse Events

Serious infections: Occur at a rate of 0.015 per patient-year 5
Mucosal and cutaneous candidiasis: More frequently reported with secukinumab than placebo 1, 5, 3
Neutropenia: Occurs more frequently than placebo, though most cases are mild, transient, and reversible; rare Grade 4 neutropenia reported 5, 3
Hypersensitivity reactions: Including rare anaphylactic reactions 3

Management of Infections

Advise patients to seek medical advice if signs/symptoms of infection occur 1
Monitor patients with serious infection closely and do not administer secukinumab until infection resolves 1
Non-serious mucocutaneous candida infections can be managed with standard antifungal therapy while continuing secukinumab 1

Administration Details

Subcutaneous Administration

Allow medication to reach room temperature before injection (15-30 minutes for most formulations; 30-45 minutes for UnoReady pen and 300 mg/2 mL prefilled syringe) 2
Inject at different anatomic locations (upper arms, thighs, or any quadrant of abdomen) than previous injection 2
Avoid areas where skin is tender, bruised, erythematous, indurated, or affected by psoriasis 1, 2
Adult patients may self-administer after proper training; pediatric patients should not self-administer 2

Intravenous Administration (Adults Only)

Available for psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis 2
Requires dilution prior to administration 2
Administer as 30-minute infusion 2
Must be administered by healthcare professional in healthcare setting 2

Pregnancy and Lactation

Preferably avoid use during pregnancy 1
Women of childbearing potential: Use effective contraception during treatment and for at least 20 weeks after discontinuation 1
Breastfeeding: Unknown if secukinumab is excreted in human breast milk; clinical decision should weigh benefit of breastfeeding to child versus benefit of therapy to mother 1

Key Clinical Pearls

The 300 mg dose is superior to 150 mg for plaque psoriasis with comparable safety 1
Secukinumab demonstrates high drug survival rates (87% at 132 weeks) in real-world practice 6
Neutralizing antibodies are rare (<0.4%) and not associated with loss of efficacy 1
Secukinumab showed non-inferior efficacy to adalimumab in head-to-head trial with higher treatment retention rate 7
Latex warning: Removable caps of Sensoready pen and certain prefilled syringes contain natural rubber latex 1, 2

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