How should secukinumab (Cosentyx UnoReady) be prescribed for an adult with moderate-to-severe plaque psoriasis, active psoriatic arthritis, or active ankylosing spondylitis after conventional systemic therapy has been insufficient or not tolerated?

How to Prescribe Secukinumab (Cosentyx UnoReady)

Prescribe secukinumab 300 mg subcutaneously at weeks 0,1,2,3, and 4, followed by 300 mg every 4 weeks indefinitely for moderate-to-severe plaque psoriasis, active psoriatic arthritis (with coexistent moderate-to-severe psoriasis), or active ankylosing spondylitis after completing mandatory pre-treatment screening for tuberculosis, active infections, and hepatitis B. 1, 2

Pre-Treatment Screening Requirements (Mandatory Before First Dose)

• Screen for active and latent tuberculosis using tuberculin skin test or interferon-gamma release assay; do not initiate secukinumab in patients with active TB. 1, 2
• Initiate anti-tuberculosis therapy before starting secukinumab in patients with latent TB infection. 1, 2
• Screen for active infections or sepsis; defer therapy until resolved, and consult infectious disease specialists if considering initiation during active infection. 1
• Screen for hepatitis B infection; untreated hepatitis B is a relative contraindication. 1
• Assess history of inflammatory bowel disease (IBD); secukinumab may trigger or exacerbate IBD and should be avoided in patients with active or prior IBD. 1, 3
• Complete all age-appropriate killed vaccines before initiating therapy; live attenuated vaccines must be administered at least 2-4 weeks before starting secukinumab and are absolutely contraindicated once therapy begins. 1, 2
• Administer pneumococcal vaccine and ensure annual influenza vaccination is up to date before starting therapy. 1

Dosing Regimens by Indication

Moderate-to-Severe Plaque Psoriasis (Adults)

• Administer 300 mg subcutaneously at weeks 0,1,2,3, and 4 (loading phase), then 300 mg every 4 weeks starting at week 8 (maintenance phase). 1, 2
• Each 300 mg dose is given as one 300 mg injection or two 150 mg injections. 2
• The 300 mg dose is superior to 150 mg, achieving 79% PASI 90 response at week 16 versus lower rates with 150 mg. 1, 4
• For some patients, 150 mg may be acceptable, but 300 mg should be prioritized for optimal efficacy. 2

Psoriatic Arthritis (Adults)

• For patients with PsA and coexistent moderate-to-severe plaque psoriasis, use the 300 mg dosing regimen described above for plaque psoriasis. 2
• For other adult patients with PsA, administer 150 mg at weeks 0,1,2,3, and 4, then 150 mg every 4 weeks. 2
• If active PsA persists despite 150 mg dosing, escalate to 300 mg every 4 weeks. 2
• Secukinumab may be administered with or without methotrexate. 2

Ankylosing Spondylitis (Adults)

• Administer 150 mg at weeks 0,1,2,3, and 4, then 150 mg every 4 weeks. 2
• If active AS persists, escalate to 300 mg every 4 weeks. 2
• Alternatively, initiate at 150 mg every 4 weeks without a loading phase. 2

Pediatric Plaque Psoriasis (≥6 Years)

• For patients <50 kg: administer 75 mg at weeks 0,1,2,3, and 4, then 75 mg every 4 weeks. 2
• For patients ≥50 kg: administer 150 mg at weeks 0,1,2,3, and 4, then 150 mg every 4 weeks. 2

Juvenile Psoriatic Arthritis (≥2 Years)

• For patients ≥15 kg and <50 kg: administer 75 mg at weeks 0,1,2,3, and 4, then 75 mg every 4 weeks. 2
• For patients ≥50 kg: administer 150 mg at weeks 0,1,2,3, and 4, then 150 mg every 4 weeks. 2

Administration Technique

• Inject subcutaneously in the upper arms, thighs, or any abdominal quadrant; rotate injection sites with each dose. 1, 2
• Avoid injecting into areas with active psoriasis lesions, or skin that is tender, bruised, erythematous, or indurated. 1, 2
• Adult patients may self-administer after proper training; pediatric patients should not self-administer. 2
• Upper outer arm injections must be performed by a caregiver or healthcare provider. 2

Duration of Therapy and Response Assessment

• Continue maintenance dosing every 4 weeks indefinitely without a predetermined stopping point. 1
• Assess response at week 16; discontinue if no clinical response is achieved by this timepoint. 1
• Response is sustained through at least 52 weeks and can be maintained for 2-5 years with continuous dosing. 1, 5
• Do not extend the dosing interval to every 6 weeks, even in patients achieving early PASI 90 responses; this significantly reduces efficacy. 1
• Do not use "as-needed" or intermittent dosing after the loading phase; continuous every-4-week dosing is essential. 1

Safety Monitoring During Therapy

• Monitor for mucocutaneous candida infections (1.9 events per 100 patient-years); these are typically mild and respond to standard antifungal treatment without requiring discontinuation. 1
• Monitor for serious infections (0.015 events per patient-year); temporarily discontinue secukinumab until infection resolves. 1
• Watch for new-onset or worsening inflammatory bowel disease; immediately discontinue secukinumab if IBD develops or worsens. 1
• Neutropenia may occur but is usually mild, transient, and reversible. 1
• Development of neutralizing antibodies occurs in <1% of patients and rarely impacts efficacy. 1

Combination Therapy Considerations

• Combination with high-potency topical corticosteroids with or without vitamin D analogues may augment efficacy, though published safety data on combinations is limited. 1
• Do not combine secukinumab with other biologics; such combinations carry unknown risks. 1
• Secukinumab is recommended as monotherapy for all approved indications. 1

Patient Selection Considerations

• Secukinumab is the preferred first-line biologic for moderate-to-severe plaque psoriasis without psoriatic arthritis, achieving superior PASI 90 response (79%) compared to ustekinumab (57.6%) at week 16. 4
• For patients with concurrent psoriatic arthritis, consider ustekinumab as first-line if musculoskeletal disease is the primary concern. 4
• For patients with a history of inflammatory bowel disease, choose ustekinumab instead of secukinumab due to the risk of IBD exacerbation with IL-17A inhibition. 4, 3
• Secukinumab is strongly recommended for moderate-to-severe nail involvement, palmoplantar plaque psoriasis, and psoriasis with psoriatic arthritis. 1

Common Pitfalls to Avoid

• Do not use the 150 mg dose when 300 mg is appropriate for plaque psoriasis; the higher dose provides markedly greater efficacy with comparable safety. 1
• Do not delay treatment for killed vaccines; these can be administered after starting therapy, but live vaccines must be given before initiation. 1
• Do not initiate therapy during active infection without infectious disease consultation. 1
• Do not continue therapy beyond 16 weeks if no response is observed; consider switching to an alternative biologic. 6, 1