When should secukinumab (Cosentyx) be started in patients with moderate to severe plaque psoriasis?

When to Start Secukinumab in Psoriasis

Secukinumab should be started in adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy, with treatment initiated at 300 mg subcutaneously at weeks 0,1,2,3, and 4, followed by 300 mg every 4 weeks. 1, 2

Patient Selection Criteria

Disease Severity Requirements

• Moderate-to-severe plaque psoriasis is the primary indication, defined by patients requiring systemic therapy or phototherapy 1, 2
• The FDA approval specifically covers patients 6 years and older who meet these severity criteria 2
• Patients with inadequate response to topical therapies alone are appropriate candidates 1

Specific Psoriasis Subtypes Where Secukinumab Should Be Started

High-priority indications (Strength A recommendations):

• Nail psoriasis: Secukinumab is strongly recommended as monotherapy for moderate-to-severe nail involvement 1
• Palmoplantar plaque psoriasis: Secukinumab is strongly recommended for moderate-to-severe palms and soles disease 1
• Psoriasis with psoriatic arthritis: Secukinumab may be used when both skin and joint disease are present 1

Moderate-priority indications (Strength B-C recommendations):

• Scalp psoriasis: Secukinumab can be recommended for moderate-to-severe head and neck involvement including scalp 1
• Palmoplantar pustulosis: Secukinumab can be recommended for this variant 1
• Erythrodermic psoriasis: Secukinumab can be used as monotherapy 1

Standard Dosing Protocol at Initiation

Loading Phase (Weeks 0-4)

• 300 mg subcutaneous injection is the recommended starting dose 1, 2
• Administered at week 0, week 1, week 2, week 3, and week 4 1
• The 300 mg dose is more effective than 150 mg and should be prioritized 1
• Self-administration by subcutaneous injection is the standard route 1

Maintenance Phase (After Week 4)

• 300 mg every 4 weeks starting at week 8 and continuing indefinitely 1
• The recommended maintenance dose after the initial 12 weeks remains 300 mg every 4 weeks 1
• As-needed dosing after 12 weeks is less effective than continued every-4-week dosing and should be avoided 1

Clinical Response Timeline

Expected Response Rates

• Peak efficacy occurs at week 16 in clinical trials 3
• 50% reduction in mean PASI is achieved after approximately 2.9 weeks with 300 mg dosing 3
• At week 16, 79% of patients achieve PASI 90 with 300 mg secukinumab 1
• Response is maintained through 52 weeks and beyond with continued dosing 1, 4

Long-term Efficacy

• At 3 years (week 152), PASI-90 is achieved in 69.2% and PASI-100 in 53.8% of patients on 300 mg fixed-interval dosing 4
• Real-world data at 136 weeks shows 79% achieve PASI 75, 72% achieve PASI 90, and 55% achieve PASI 100 5

Pre-Treatment Considerations

Screening Requirements

• Screen for active tuberculosis before initiating therapy 1
• Screen for active infections or sepsis; initiation during active infection should be done in consultation with infectious disease specialists 1
• Screen for untreated hepatitis B infection (relative contraindication) 1
• Assess for history of inflammatory bowel disease, as secukinumab may increase risk of IBD events 1

Absolute Contraindications

• History of allergic reaction to secukinumab or vehicle 1
• Active infection requiring treatment should delay initiation until full resolution 1

Special Populations

Biologic-Naïve Patients

• Biologic treatment-naïve status is significantly associated with better response to secukinumab at 1 and 2 years (P < 0.0001) 5
• These patients should be prioritized for secukinumab initiation when systemic therapy is indicated 5

Patients with Comorbidities

• Secukinumab can be safely initiated in patients with controlled hepatitis B, hepatitis C, or latent tuberculosis with appropriate monitoring 5
• No specific laboratory monitoring beyond standard care is required during treatment 6

Common Pitfalls to Avoid

Dosing Errors

• Do not use 150 mg dosing as first-line; the 300 mg dose demonstrates superior efficacy with similar safety 1
• Do not switch to as-needed dosing after 12 weeks; continuous every-4-week dosing maintains superior efficacy 1
• Do not skip the weekly loading doses (weeks 0-4); this regimen is critical for rapid disease control 1

Safety Monitoring

• Monitor for mucocutaneous candida infections, which occur at 1.9 per 100 patient-years but are typically mild and responsive to standard treatment 1, 7
• Avoid in patients with active IBD or strong history of IBD, as secukinumab may worsen inflammatory bowel disease 1, 7
• Serious infections occur at low rates (0.015 per patient-year) but require treatment discontinuation until resolved 1

Immunogenicity

• Neutralizing antibodies develop in <1% of patients through 52 weeks and are not associated with loss of efficacy 1
• This low immunogenicity rate supports long-term continuous use without routine antibody testing 1

Combination Therapy Considerations

• Combination with topical corticosteroids or vitamin D analogues may be considered, though there is no published safety data on combinations 1
• No evidence supports combining secukinumab with other biologics, and such combinations carry unknown risks 1
• Secukinumab is recommended as monotherapy for all approved indications 1