What is the recommended treatment protocol for Secukinumab (secukinumab) in an adult patient with moderate to severe plaque psoriasis?

Secukinumab Treatment Protocol for Moderate to Severe Plaque Psoriasis

The recommended treatment protocol for secukinumab in adults with moderate-to-severe plaque psoriasis is 300 mg subcutaneously at weeks 0,1,2,3, and 4, followed by 300 mg every 4 weeks as maintenance therapy. 1, 2

Induction Phase Dosing

• Administer 300 mg subcutaneously at weeks 0,1,2,3, and 4 as the loading regimen 1, 3
• The 300 mg dose is administered as two separate 150 mg injections 3
• Self-administration by subcutaneous injection is the standard route of delivery 2, 4

Maintenance Phase Dosing

• After the initial 12-week period, continue with 300 mg every 4 weeks 1, 2
• The 300 mg dose is more effective than 150 mg and should be prioritized (Level A recommendation) 1
• Steady-state concentrations are achieved by week 24 with this regimen 3

Pre-Treatment Screening Requirements

Before initiating secukinumab, the following screening is mandatory:

• Screen for active tuberculosis prior to treatment initiation 2
• Screen for active infections or sepsis; if present, consult infectious disease specialists before starting therapy 2
• Assess for untreated hepatitis B infection, which is a relative contraindication 2
• Evaluate for history of inflammatory bowel disease, as secukinumab may increase the risk of IBD events 2

Expected Clinical Response Timeline

• At week 16, 79% of patients achieve PASI 90 with the 300 mg dose 1, 2
• Response is maintained through 52 weeks and beyond with continued every 4 weeks dosing 1
• Assess definitive treatment response at 12 weeks of continuous therapy 2
• Efficacy increases progressively to week 16 and is maintained to week 52 4

Dose Optimization for Suboptimal Responders

For patients who achieve PASI 75 but not PASI 90 at week 24:

• Continue standard every 4 weeks dosing as the primary strategy 5
• Consider every 2 weeks dosing for patients weighing ≥90 kg who have not achieved PASI 90 at week 24 5
• Every 6 weeks dosing is not recommended as it fails to maintain PASI 90 response (74.9% vs 85.7% with every 4 weeks dosing) 5

The evidence from the OPTIMISE trial demonstrates that standard every 4 weeks dosing maintains PASI 90 in 85.7% of responders, while extending to every 6 weeks results in inferior outcomes 5. Intensified every 2 weeks dosing showed numerical benefit in heavier patients (≥90 kg) with suboptimal response, though this did not reach statistical significance 5.

Special Populations and Indications

Secukinumab is recommended as monotherapy for specific psoriasis presentations:

• Scalp and head/neck involvement (Level B recommendation) 1
• Nail psoriasis (Level A recommendation) 1, 2
• Palmoplantar plaque psoriasis (Level A recommendation) 1, 2
• Palmoplantar pustulosis (Level B recommendation) 1
• Erythrodermic psoriasis (Level C recommendation) 1
• Psoriasis with concurrent psoriatic arthritis (Level A recommendation) 1, 2

Safety Monitoring

Key safety considerations during treatment:

• Monitor for mucocutaneous candida infections, which occur at 1.9 per 100 patient-years but are typically mild and responsive to standard antifungal treatment 2
• Serious infections occur at low rates (0.015 per patient-year) but require treatment discontinuation until resolved 2
• Neutralizing antibodies develop in less than 1% of patients and are not associated with loss of efficacy 1
• The mean elimination half-life is 22-31 days 3

Combination Therapy Considerations

• Secukinumab is recommended as monotherapy for all approved indications 2
• Combination with topical corticosteroids or vitamin D analogues may be considered, though there is no published safety data on such combinations 1, 2
• Do not combine with other biologics due to unknown risks 2

Patient-Reported Outcomes

Beyond PASI scores, secukinumab demonstrates significant improvements in:

• Itching, pain, and scaling symptoms compared to placebo (all P < 0.0001 at week 12) 6
• Quality of life measures, with more patients achieving minimal disease activity 7
• Self-administration acceptability is high throughout treatment 4

Common Pitfalls to Avoid

• Do not extend dosing intervals to every 6 weeks in PASI 90 responders, as this compromises efficacy 5
• Do not use the 150 mg dose when 300 mg is appropriate, as the higher dose demonstrates superior efficacy with equal safety 1
• Do not discontinue therapy prematurely; continued every 4 weeks treatment can improve response even after 16 weeks 7
• Do not initiate during active infection without infectious disease consultation 2