What are the recommended dosing regimens for biologics (biologic medications) in the treatment of moderate to severe psoriasis and atopic dermatitis?

Biologic Dosing Regimens for Moderate to Severe Psoriasis and Atopic Dermatitis

Psoriasis: TNF-α Inhibitors

Adalimumab

The recommended starting dose of adalimumab is 80 mg subcutaneously at week 0, followed by 40 mg at week 1, then 40 mg every 2 weeks thereafter. 1

• For patients with inadequate response to standard dosing, escalate to 40 mg weekly for better disease control 1
• This dose escalation is supported by Level I-II evidence and carries a Strength A recommendation from the AAD-NPF 1
• Approximately 27.8% of patients require dose escalation in real-world practice, with 52.1% maintaining weekly dosing long-term 2
• Adalimumab demonstrates rapid response, with 57% mean PASI improvement by week 4 3

Combination therapy strategies:

• Combine with high-potency topical corticosteroids with or without vitamin D analogues (Strength B recommendation) 1
• May combine with methotrexate to augment efficacy (Strength B recommendation) 1
• May combine with acitretin, particularly for palmoplantar psoriasis, without significantly increasing immunosuppression (Strength C recommendation) 1

Infliximab

Infliximab is dosed at 5 mg/kg intravenously at weeks 0,2, and 6, then every 8 weeks for maintenance. 1

• For inadequate response, increase dosing frequency to every 6 weeks before increasing dose, up to maximum 10 mg/kg (Strength B recommendation) 1, 4
• Strongly consider adding methotrexate to all infliximab patients to reduce immunogenicity and prevent antibody formation that leads to loss of efficacy 1
• Avoid intervals longer than 8 weeks between infusions, as this increases risk of infusion reactions and treatment failure 1
• Approximately 39% of patients lose efficacy with standard maintenance dosing, supporting individualized dose optimization 4

Certolizumab

The approved dosing is 400 mg (two 200 mg subcutaneous injections) every other week. 1

• Alternative dosing for patients weighing ≤90 kg: 400 mg at weeks 0,2, and 4, followed by 200 mg every other week 1
• Phase II data showed 75-83% of patients achieved PASI 75 at week 12 1

Psoriasis: IL-12/23 Inhibitor

Ustekinumab

For patients ≤100 kg: 45 mg subcutaneously at weeks 0 and 4, then every 12 weeks. 5

For patients >100 kg: 90 mg subcutaneously at weeks 0 and 4, then every 12 weeks. 5

• For inadequate response in patients ≤100 kg, escalate to 90 mg every 12 weeks (Strength A recommendation) 1
• For inadequate response in patients >100 kg, shorten interval to 90 mg every 8 weeks (Strength A recommendation) 1
• The 90 mg dose demonstrates superior efficacy in patients >100 kg compared to 45 mg 5

Combination therapy:

• May combine with topical corticosteroids and vitamin D analogues (Strength C recommendation) 1
• May combine with acitretin or methotrexate (Strength B recommendation) 1
• May combine with narrowband UVB phototherapy (Strength B recommendation) 1

Pediatric dosing (6-17 years):

• <60 kg: 0.75 mg/kg at weeks 0 and 4, then every 12 weeks 5
• 60-100 kg: 45 mg at weeks 0 and 4, then every 12 weeks 5

• 100 kg: 90 mg at weeks 0 and 4, then every 12 weeks 5

Psoriatic Arthritis Considerations

When psoriatic arthritis is present, adalimumab is particularly recommended as first-line biologic therapy (Strength A recommendation). 1

• Ustekinumab dosing for psoriatic arthritis follows the same weight-based regimen as psoriasis 5
• For patients >100 kg with co-existent moderate-to-severe plaque psoriasis and psoriatic arthritis, use 90 mg every 12 weeks 5
• Infliximab carries Strength A recommendation for psoriatic arthritis, with methotrexate co-medication strongly advised 4

Weight-Based Dosing Considerations

Overweight and obese patients are less likely to respond to TNF-α inhibitors and frequently require shorter dose intervals or higher doses. 1

• This effect is abrogated with infliximab due to its weight-based dosing (5 mg/kg) 1
• For ustekinumab, the 90 mg dose in patients >100 kg addresses this weight-response relationship 5

Dose Escalation Principles

Consider dose escalation when patients demonstrate inadequate primary response or relapse during treatment cycles. 1

• Escalation may be associated with increased infection risk 1
• Real-world data shows dose escalation rates of 0-67% depending on the biologic agent 6
• For infliximab specifically, increase frequency before increasing dose 1

Atopic Dermatitis

The provided evidence focuses exclusively on psoriasis and psoriatic arthritis biologics. For atopic dermatitis, the approved biologics include dupilumab (IL-4/IL-13 inhibitor) and tralokinumab (IL-13 inhibitor), which are not covered in the current evidence base.