Anti-TNF switch may help some psoriasis patients

By Reuters Staff

NEW YORK (Reuters Health) - Switching to a different TNF-alfa inhibitor can be effective in some patients with psoriasis, particularly those who respond initially and then lose the response (secondary inefficacy), report clinicians from Italy.

However, for those patients who show primary inefficacy, the value of switching to another agent is less clear, they say.

"It is not uncommon for physicians to switch patients from one TNF-alfa inhibitor to another when there is an inadequate response or an adverse event," Dr. Stefano Piaserico from the University of Padua and colleagues say.

Treatment options for psoriasis continue to increase as new biological agents with different mechanisms of action are becoming available. Yet, the best therapeutic strategy for patients with an inadequate response to a first cycle of biologics remains "an unanswered question that often arises in clinical practice," they write in the Journal of the American Academy of Dermatology, online December 16.

They assessed variables predicting the efficacy of switching between TNF-alfa inhibitors in 105 patients with psoriasis included in the Italian Psocare Registry.

The majority of patients (60%) switched from etanercept to a monoclonal antibody, 21% switched from a monoclonal antibody to etanercept, and 18% switched from one monoclonal antibody to another.

The reason for switching to a second TNF inhibitor was primary inefficacy (PASI 75 never achieved) in 47 cases (45%), secondary loss of efficacy (loss of initial PASI 75 response) in 23 (22%), and adverse events/other in 35 (33%). Patients who switched had been treated with the first TNF-alfa inhibitor for an average of 58 weeks.

The researchers say a cumulative PASI 75 response rate was attained in 29%, 46%, and 74% of patients at 16, 24, and 52 weeks, respectively, after switching to the second TNF-alfa inhibitor.

After 16 and 24 weeks of treatment with a second TNF-alfa inhibitor, PASI 75 was reached by 14% and 30%, respectively, being treated with etanercept; by 27% and 40% being treated with infliximab; and by 38% and 58% being treated with adalimumab.

Patients who switched due to secondary loss of efficacy or adverse events/intolerance were more apt to reach PASI 75 than those who switched as a result of primary inefficacy (PASI 75 never achieved) (hazard ratio, 2.7 vs. 2.0).

"Improvement in symptom severity in patients with a history of primary inefficacy is of course advantageous and desirable despite a debatable cost-benefit profile," Dr. Piaserico and colleagues write. "Using a drug with a different mechanism of action seems opportune in these cases in view of the patients' lower rate of response to a second TNF-alfa inhibitor with respect to that noted in patients continuing with the first."

"Needless to say, treatments should always be tailored to each patient's needs taking into account his/her characteristics (traditional drug use and tolerance, comorbidities, weight) and preferences (mode and frequency of drug administration) and, when it comes to switching from a TNF-alfa inhibitor to another drug, the reason the first was discontinued," they add.

Dr. Piaserico did not respond to request for comment by press time.


J Am Acad Dermatol 2013.

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