Clinical Practice Guidelines for Biologic Therapy for Psoriasis (BAD, 2020)

British Association of Dermatologists

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2020

Clinical practice guidelines for biologic therapy for psoriasis were updated in October 2020 by the British Association of Dermatologists.[1]

Use of Biologic Therapy  

Biologic therapy for psoriasis should be initiated and supervised only by specialist physicians who are experienced in the diagnosis and treatment of psoriasis. The routine monitoring can be delegated to other healthcare professionals, such as clinical nurse specialists. Other relevant healthcare professionals should be consulted in cases that involve psoriatic arthritis or other multiple comorbidities.

Coordination of care providers, along with the patient, is necessary with regard to arrangements for drug administration, monitoring, and follow-up.

Ensure that people with psoriasis who are starting biologic therapy have an opportunity to participate in long-term safety registries.

Criteria for Use of Biologic Therapy  

Criteria for offering biologic therapy are as follows:

  • Psoriasis requiring systemic therapy

  • Failure of, intolerance to, or contraindications for methotrexate and cyclosporine

  • Psoriasis has significant impact on physical, psychological, or social functioning: Extensive (>10% body surface area or Psoriasis Area and Severity Index ≥10) and/or psoriasis is severe at localized sites and is associated with significant functional impairment

Criteria for considering biologic therapy are as follows:

  • Psoriasis that fulfills disease severity criteria and is accompanied by active psoriatic arthritis

  • Psoriasis that is persistent (eg, relapses rapidly) when off therapy that cannot be continued long term

Choice of Biologic Therapy

Considerations to take into account before initiating or making changes to biologic therapy are as follows:

  • The presence of both psoriasis and psoriatic arthritis, in consultation with a rheumatologist

  • Presence and phenotype of psoriatic arthritis, which may influence access to and choice and dose of biologic therapy

The following psoriasis-related factors should be considered when tailoring the choice of biologic agent to the needs of the patient:

  • Therapeutic goals

  • Disease phenotype and activity pattern

  • Disease severity and impact

  • Additional presence of psoriatic arthritis

  • Outcomes of prior psoriasis treatments

Other individual factors to consider when tailoring the choice of biologic agent to the needs of the patient are as follows:

  • Patient age

  • Current or past comorbidities

  • Pregnancy status and/or conception plans

  • Patient body weight

  • Patient opinion on drug administration route or dosing frequency

  • Likelihood of compliance with treatment

  • Drug cost: Administration expense, dosage, price per dose, commercial arrangements

In adults, offer any of the currently approved biologic therapies as first-line therapy, substituting a different approved biologic should the first one fail. Tumor necrosis factor (TNF) antagonists or interleukin 17 antagonists should be offered as first-line therapy for patients with psoriatic arthritis. Etanercept can be considered in TNF antagonist–eligible patients if other biologics have failed or cannot be used, or if a short half-life is important. Infliximab should be reserved for very severe disease or if age-based dosing is important, or if other biologics have failed or cannot be used.

For pediatric patients, adalimumab can be offered for patients aged 4 years or older, etanercept for patients aged 6 years or older, or ustekinumab for those aged 12 years or older, if they meet the criteria for biologic therapy. If these agents do not provide an adequate response, a specialist in pediatric biologic therapy should be consulted, along with consideration of the following:

  • Advice about factors that may be contributing to the poor response, such as obesity and poor compliance

  • Optimization of adjunctive therapy, such as switching from oral to subcutaneous methotrexate

  • Supplementary or alternative nonbiologic therapies, such as inpatient topical therapy or systemic therapies

Important Contraindications to Biologic Therapies  

Contraindications for the use of biologic therapies in psoriasis patients are as follows:

  • TNF antagonist use with demyelinating diseases (and possible use of alternative therapies in those with first-degree relatives with demyelinating disease)

  • TNF antagonist use with severe cardiac failure (New York Heart Association class III and IV)

  • Inflammatory bowel disease, which warrants gastroenterology specialist consultation before offering brodalumab, ixekizumab, or secukinumab

  • Relative contraindication in people undergoing elective surgery

For more information, see Psoriasis.

For more Clinical Practice Guidelines, go to Guidelines.

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