New Clinical Practice Guidelines, October 2017

Psoriasis Biologic Therapy

Guidelines on biologic therapy for psoriasis by the British Association of Dermatologists^[23]

Offer biologic therapy to people with psoriasis requiring systemic therapy if methotrexate and cyclosporine have failed, if they are not tolerated or are contraindicated, and if the psoriasis has a large impact on physical, psychological, or social functioning (eg, Dermatology Life Quality Index [DLQI] or Children's DLQI >10 or clinically relevant depressive or anxiety symptoms) and one or more of the following disease severity criteria apply:

• The psoriasis is extensive (defined as body surface area [BSA] >10% or Psoriasis Area and Severity Index [PASI] ≥10)

• The psoriasis is severe at localized sites and associated with significant functional impairment and/or high levels of distress (eg, nail disease or involvement of high-impact and difficult-to-treat sites such as the face, scalp, palms, soles, flexures, and genitals).

Consider biologic therapy earlier in the treatment pathway (eg, if methotrexate has failed, is not tolerated, or is contraindicated) in people with psoriasis who fulfill the disease severity criteria and who also have active psoriatic arthritis or who have psoriasis that is persistent (ie, that relapses rapidly [defined as >50% baseline disease severity within 3 months of completion of any treatment]) off a therapy that cannot be continued in the long-term (eg, narrowband ultraviolet B).

Assess whether the minimal response criteria have been met, as defined by the following:

• ≥50% reduction in baseline disease severity (eg, PASI 50 response, or percentage BSA where PASI is not applicable) and

• Clinically relevant improvement in physical, psychological or social functioning (eg, ≥4-point improvement in DLQI or resolution of low mood).

Offer ustekinumab as a first-line biologic agent to adults with psoriasis who fulfil the criteria for biologic therapy.

Offer adalimumab as a first-line biologic agent to adults with psoriasis particularly when psoriatic arthropathy is a consideration.

Consider secukinumab as a first-line biologic agent in adults with psoriasis, with or without psoriatic arthritis.

Reserve infliximab for use in people with very severe disease or where other available biologic agents have failed or cannot be used.

Offer adalimumab (age ≥4 years), etanercept (≥6 years) or ustekinumab (≥12 years) to children and young people who fulfill the criteria for biologic therapy.

Advise women of childbearing potential who are starting biologic therapy for psoriasis to use effective contraception and discuss conception plans with the consultant supervising their care (There are no known interactions between biologic therapies and contraceptive methods).

Advise mothers who have received biologic therapy for psoriasis beyond 16 weeks' gestation that their infants should not receive any live vaccinations until they have reached 6 months of age (eg, rotavirus and BCG).

Do not give live vaccines to people on biologic therapy or to infants (up to 6 months of age) whose mothers have received biologic therapy beyond 16 weeks' gestation.

Stop biologic therapy for at least 6 months before giving live vaccines, and for 12 months in the case of shingles (herpes zoster) vaccine. In general, biologic therapy can be started 4 weeks after administration of a live vaccine.

Where possible, complete all required vaccinations prior to initiation of biologic therapy, and review vaccination requirements during therapy with reference to the Green Book and the clinical risk category 'immunosuppression.'

Do not use TNF antagonists in people with demyelinating diseases, and review alternative interventions in people who have an affected first-degree relative with demyelinating disease.

Stop treatment and seek specialist advice if neurologic symptoms suggestive of demyelinating disease develop during TNF antagonist therapy. Symptoms include loss or reduction of vision in one eye with painful eye movements; double vision; ascending sensory disturbance and/or weakness; problems with balance, unsteadiness or clumsiness; and altered sensation traveling down the back and sometimes into the limbs when bending the neck forward.

Avoid TNF antagonist therapy in people with severe cardiac failure.

Stop TNF antagonist therapy in the event of new or worsening preexisting heart failure and seek specialist advice.

Exercise caution and consult a gastroenterology specialist before using secukinumab or ixekizumab in people with inflammatory bowel disease.

See Psoriasis

Medscape © 2017 WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: John Anello, Brian Feinberg, John Heinegg, et. al. New Clinical Practice Guidelines, October 2017 - Medscape - Oct 06, 2017.