What are the next treatment options for a patient with chronic plaque psoriasis who has not achieved remission with secukinumab (Cosentyx) and adalimumab (Humira)?

From the Guidelines

For a patient with skin psoriasis who has failed to respond to both secukinumab and adalimumab, I recommend switching to ustekinumab, which is an IL-12/23 inhibitor with a different mechanism of action, as suggested by the British Association of Dermatologists guidelines for biologic therapy for psoriasis 2017 1.

The patient's failure to respond to secukinumab and adalimumab indicates a need to consider alternative biologic therapies. According to the pathway algorithm provided in the guidelines, if a person fails the first biologic therapy, they should be considered for switching to an alternative biologic therapy, and any of the currently licensed therapies can be offered, with the choice tailored to the needs of the person 1.

Key considerations in choosing the next biologic therapy include:

• The presence of psoriatic arthritis, which may influence the choice of biologic therapy
• The patient's response to previous treatments and any treatment-limiting side effects
• The patient's comorbidities, age, and other factors that may affect the choice of biologic therapy

Ustekinumab is a suitable option for patients with psoriasis who have failed other biologic therapies, as it targets a different inflammatory pathway. The dosing schedule for ustekinumab is typically 45 mg or 90 mg at weeks 0 and 4, and then every 12 weeks, with the choice of dose depending on the patient's weight and other factors 1.

Before switching to ustekinumab, it is essential to ensure that the patient has received adequate dosing and duration of previous treatments and to rule out any treatment-limiting infections or other contraindications. Additionally, combination therapy with methotrexate may be considered to enhance efficacy, although this should be decided on a case-by-case basis.

From the Research

Treatment Options for Psoriasis

• The patient has a known case of skin psoriasis and has not responded to secukinumab and adalimumab, which are both biologic therapies used to treat psoriasis 2, 3.
• A study published in 2019 found that switching from IL-17 inhibitors (such as secukinumab) to TNF inhibitors (such as adalimumab) or IL-12/23 inhibitors (such as ustekinumab) can be a safe and effective therapeutic strategy for patients with psoriasis who have not responded to initial treatment 3.
• Another study published in 2022 found that ustekinumab, guselkumab, and ixekizumab had higher drug survival rates compared to adalimumab and secukinumab, indicating better effectiveness and safety profiles for these biologics in the treatment of psoriasis 4.

Alternative Therapies

• Ustekinumab, an IL-12/23 inhibitor, has been shown to be effective in the treatment of psoriasis, particularly in patients who have not responded to TNF inhibitors such as adalimumab 5, 6.
• Guselkumab, an IL-23 inhibitor, has also been shown to have a high drug survival rate and may be a viable alternative for patients who have not responded to other biologics 4.
• Ixekizumab, an IL-17 inhibitor, has also been shown to be effective in the treatment of psoriasis, although its drug survival rate was similar to that of secukinumab 4.

Considerations for Treatment Switching

• When switching between biologics, it is essential to consider the patient's individual factors, such as psoriatic arthritis, previous biologic exposure, nail involvement, and ethnicity, which can affect treatment outcomes and drug survival 4.
• The decision to switch to a different biologic should be based on the patient's specific needs and medical history, as well as the potential benefits and risks associated with each treatment option 3, 4.