What are the biologic therapy options for patients?

Biologic Therapy Options for Psoriasis and Psoriatic Arthritis

For adults with psoriasis requiring biologic therapy, offer ustekinumab, adalimumab, or secukinumab as first-line agents, with adalimumab being the preferred choice when psoriatic arthropathy is present. 1

First-Line Biologic Agents for Adults

The British Association of Dermatologists provides clear guidance on initial biologic selection:

• Ustekinumab is recommended as a first-line biologic agent for adults with psoriasis who fulfill criteria for biologic therapy 1

  • Dosing: 45 mg every 12 weeks for patients <100 kg; 90 mg every 12 weeks for patients >100 kg 1, 2
  • Can be dose-escalated to 90 mg every 8 weeks in patients >100 kg if inadequate response 1

• Adalimumab is recommended as a first-line biologic agent, particularly when psoriatic arthropathy is a consideration 1, 2

  • Standard dosing: 40 mg every other week 1, 2
  • Can be escalated to 40 mg weekly if needed 1
  • Concomitant methotrexate reduces antibody formation (1% vs 12% with monotherapy) but is not required 3

• Secukinumab should be considered as a first-line biologic agent in adults with psoriasis, with or without psoriatic arthritis 1

• Infliximab should be reserved for people with very severe disease or where other available biologic agents have failed or cannot be used 1

  • Dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 1
  • Can be escalated to every 6 weeks if inadequate response 1

Biologic Options for Psoriatic Arthritis

For patients with active psoriatic arthritis, the American College of Rheumatology/National Psoriasis Foundation provides the following hierarchy:

Treatment-Naïve Patients

• TNF inhibitors are recommended as first-line biologic therapy over IL-17 inhibitors, IL-12/23 inhibitors, abatacept, or tofacitinib 1
• IL-17 inhibitors are recommended over IL-12/23 inhibitors, abatacept, or tofacitinib 1
• IL-12/23 inhibitors are recommended over abatacept or tofacitinib 1

After TNF Inhibitor Failure

When psoriatic arthritis remains active despite TNF inhibitor therapy:

• Switch to a different TNF inhibitor is recommended over switching to IL-12/23 inhibitor, IL-17 inhibitor, abatacept, or tofacitinib 1
• IL-17 inhibitors may be used instead of another TNF inhibitor, particularly with severe psoriasis 1
• IL-12/23 inhibitors may be used instead of another TNF inhibitor with severe psoriasis or if less frequent administration is preferred 1
• IL-17 inhibitors are recommended over IL-12/23 inhibitors, abatacept, or tofacitinib 1

Special Clinical Scenarios

Predominant Enthesitis

• TNF inhibitors are recommended over oral small molecules as first-line therapy 1
• After oral small molecule failure, TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors are recommended over switching to another oral agent 1

Concomitant Inflammatory Bowel Disease

• Monoclonal antibody TNF inhibitors (excludes etanercept) are strongly recommended over other biologics 1
• IL-12/23 inhibitors should be used over IL-17 inhibitors (IL-17 inhibitors can worsen IBD) 1
• Monoclonal antibody TNF inhibitors are recommended over IL-12/23 inhibitors 1

Pediatric Considerations

For children and young people requiring biologic therapy:

• Adalimumab (age ≥4 years), etanercept (≥6 years), or ustekinumab (≥12 years) should be offered 1

Managing Treatment Failure

Primary Failure (Inadequate Initial Response)

Consider changing to an alternative biologic therapy when:

• Psoriasis does not achieve ≥50% reduction in baseline disease severity AND clinically relevant improvement in functioning 1
• Any currently licensed biologic therapy may be offered when psoriasis has not responded to a first biologic 1

Secondary Failure (Loss of Response)

• Switch to an alternative biologic agent from a different class 1
• Address modifiable factors (obesity, poor adherence) 1
• Consider dose escalation before switching (see table above) 1

After Multiple Biologic Failures

When inadequate response to a second or subsequent biologic agent:

• Seek advice from a clinician with expertise in biologic therapy 1
• Optimize adjunctive therapy (e.g., switch from oral to subcutaneous methotrexate) 1
• Consider non-biologic approaches (inpatient topical therapy, phototherapy, standard systemic therapy) 1

Critical Safety Considerations

Do not combine HUMIRA (adalimumab) with other biologic DMARDs (anakinra, abatacept) or other TNF blockers due to increased risk of serious infections without added benefit. 3

• Avoid live vaccines with all TNF inhibitors 3
• Screen for tuberculosis before initiating anti-TNF therapy 4
• Monitor for serious infections, which occur more frequently with combination biologic therapy 3
• Consider pneumococcal and influenza vaccination 4

Dose Escalation Strategies

When inadequate primary response may be due to insufficient dosing (particularly in obese patients or those with disease relapse during treatment cycle), consider dose escalation, though this increases infection risk and may be off-label for some agents 1:

Agent	Standard Dose	Escalated Dose
Ustekinumab (<100 kg)	45 mg q12 weeks	90 mg q12 weeks
Ustekinumab (>100 kg)	90 mg q12 weeks	90 mg q8 weeks
Adalimumab	40 mg q2 weeks	40 mg weekly
Etanercept	50 mg weekly	50 mg twice weekly
Infliximab	5 mg/kg q8 weeks	5 mg/kg q6 weeks

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