2. Secukinumab demonstrates significant improvement of disease activity and health related quality of life in Canadian psoriasis patients in a real world setting (#7506)

3. Study Design and Methods
Trial participants were those enrolled in a patient support program for the treatment of moderate-to-severe psoriasis.
The program provided reimbursement support, access to educational tools, injection training, and supplies.
Data were collected for patients who provided consent and received at least 1 dose of secukinumab.
The post-secukinumab Psoriasis Area and Severity Index (PASI) data and Dermatology Life Quality Index (DLQI) data were limited to those whose scores were collected 12 to 51 weeks post treatment initiation.
If multiple scores were available, the ones closest to the secukinumab start date were used.

4. Study Design and Methods (cont)
2216 patients were included with an average age of 50.3 years (range 18 to 92 years); 42.6% were women.
35.2% were biologic naïve, 29.6% had received only 1 biologic previously, and 18.8% had received 2 biologics previously.
For the 1435 patients who had received 1 biologic previously, 38.3% received ustekinumab, 30.0% adalimumab, 18.3% etanercept, and 8.1% infliximab.
Post-secukinumab PASI data were available for 108 patients.
Their treatment history was similar to the overall cohort of 2216 patients.

5. Results Summary
From a mean baseline of 18.2, the PASI score decreased to 3.0 following treatment with secukinumab
A PASI <3 was achieved in 68.5% of patients overall.
A PASI <3 was achieved in 83.8% of biologic naïve and 60.6% of biologic experienced.
Pre- and post-secukinumab DLQI data were available for 236 patients.
The DLQI score changed from a mean of 19.1 at baseline to 3.6 following secukinumab treatment.
92.4% of patients achieved DLQI reduction ≥5 or DLQI 0-1.

6. Principal Investigator Commentary
3 important highlights are:
Real-world evidence suggests secukinumab to be among the best treatments for psoriasis in the majority of patients–either those that are biologic naïve or are switching from 1 previous biologic.
Irrespective of line of therapy, initial PASI response observed in this cohort demonstrates that secukinumab significantly reduces disease activity with up to 83.8% of biologic-naïve patients reaching PASI <3.
Secukinumab significantly improves quality of life.
92% reach DLQI score reduction ≥5 or DLQI 0/1 following secukinumab treatment in a real-world setting.

7. Principal Investigator Commentary
This real-world study
confirms the efficacy of secukinumab shown in phase 3 trials.
demonstrates the benefits of early treatment as biologic-naïve patients reach better outcomes compared to biologic-experienced patients.

8. Faculty Commentary
The results remind us of the importance of assessing quality of life in patients with psoriasis.
We can help our patients feel more comfortable by educating them that secukinumab modulates rather than suppresses the immune system.

9. Apremilast, an oral phosphodiesterase-4 inhibitor, in the treatment of palmoplantar psoriasis. Our experience in real clinical practice (#6086)

10. Study Design and Methods
4 patients diagnosed with moderate-to-severe palmoplantar psoriasis were treated with apremilast 30 mg twice daily for 6 to 14 months.

11. Results Summary
3 men and 1 woman with ages between 23 and 57 years comprised the cohort.
2 patients had received multiple treatment lines including biologic therapy.
2 patients achieved clear or almost clear palms and soles at 16 weeks.
The average palmoplantar pustular Psoriasis Area and Severity Index improved 68%.
One patient failed due to lack of efficacy at 6 months.
At the start of treatment, 2 patients had mild-to-moderate diarrhea that disappeared after 2 weeks of treatment.

12. Principal Investigator Commentary
Key highlights are:
Early effectiveness of apremilast in real clinical practice.
Apremilast was of clear benefit in young patients (23-57 year) who are of working age and have a poor QoL due to their disease. Positive impact on their social/ family and work life.
Only 1 of the 4 patients interrupted apremilast because of loss of efficacy at 7 months.
As of April 2018, 3 of 4 were still in treatment with a drug persistency between 14 to 24 months.
Regarding tolerability, no adverse events requiring treatment were reported other than diarrhea (mild to moderate in 2 patients).

13. Principal Investigator Commentary (cont)
Anticipated impact on patient care:
Patients with palmoplantar suffer from more physical disability and discomfort than patients with psoriasis on other parts of the body. Therefore, offering them a new treatment option to improve the course of their disease would have an important impact on their lives.
Apremilast may be considered as a new treatment option for this difficult-to-treat and rarely studied population of palmoplantar psoriasis, providing a relevant clinical benefit in these patients with a good efficacy:safety balance.

14. Faculty Commentary Palmoplantar psoriasis is very recalcitrant.
The findings of clear or almost clear lesions in 2 of the 4 patients within 4 months is highly important.
Apremilast should be investigated in a larger study of patients with palmoplantar psoriasis.

15. Retreatment with brodalumab results in high response rates in patients with psoriasis after treatment interruption (#6841)

16. Study Design and Methods
Patients with moderate-to-severe psoriasis were randomized to brodalumab 140 mg or 210 mg or placebo every 2 weeks during a 12-week induction phase.
At week 12, patients receiving brodalumab who achieved a static Physician Global Assessment (sPGA) score of 0 or 1 were re-randomized to their induction dose of brodalumab or placebo.
Beginning at week 16, all re-randomized patients who experienced return of disease (sPGA ≥3) qualified for retreatment. In these patients, brodalumab was reinitiated at their induction dose of 140 mg or 210 mg every 2 weeks.

17. Results Summary
79 of 84 patients (94%) randomized to brodalumab 210 mg every 2 weeks in the induction phase and re-randomized to placebo in the withdrawal phase experienced return of disease.
The mean and median times to return of disease were 74.7 days and 56.0 days, respectively.
Most patients with psoriasis who experienced a return of disease following brodalumab withdrawal returned to their previous level of response 16 weeks following reinitiation of brodalumab.

18. Results Summary (cont)
Of the patients who exhibited a Psoriasis Area and Severity Index (PASI) score of 75 prior to brodalumab withdrawal at week 12, 92.1% reached a PASI 75 by week 16 following reinitiation.
Of the patients who exhibited PASI 90 prior to brodalumab withdrawal, 91.2% reached a PASI 90 by week 16 following reinitiation.
Of the patients who exhibited PASI 100 prior to brodalumab withdrawal, 90.5% reached a PASI 100 score by week 16 following reinitiation.

19. Faculty Commentary
It is common for patients to discontinue and then reinitiate biologic therapy.
It is encouraging that >90% of patients treated with brodalumab regained the response achieved prior to discontinuation.

20. Efficacy of tildrakizumab in etanercept partial or nonresponders (#7636)

21. Study Design and Methods
This is a post hoc analysis of etanercept partial or nonresponders in the reSURFACE 2 trial.
Adults with moderate-to-severe psoriasis with body surface area involvement ≥10%, Physician Global Assessment (PGA) score ≥3, and Psoriasis Area and Severity Index (PASI) score ≥12.
In reSURFACE 2, patients were randomized to:
Tildrakizumab 100 mg or 200 mg on weeks 0, 4, and 16.
Etanercept 50 mg twice weekly through week 12, then once weekly through week 28.
Placebo.

22. Study Design and Methods (cont)
At week 12, placebo patients were re-randomized to tildrakizumab 100 mg or 200 mg.
At week 28, patients who were partial or nonresponders to etanercept were re-randomized to tildrakizumab 200 mg.
Partial response was defined as PASI ≥50 to <75.
Nonresponse was defined as PASI <50.

23. Results Summary
Of patients randomized to etanercept who completed 28 weeks of treatment, 39 were nonresponders and 83 partial responders.
At 52 weeks,
a PASI 75 score was achieved by 74.7% of partial responders and 53.8% of nonresponders.
a PASI 90 score was achieved by 33.7% of partial responders and 30.8% of nonresponders.
a PASI 100 score was achieved by 14.5% of partial responders and 10.3% of nonresponders.
a PGA score of 0/1 was achieved by 57.8% of partial responders and 56.4% of nonresponders.

24. Results Summary (cont)
Adverse events were similar in patients switched from etanercept to tildrakizumab at week 28 compared with patients maintained on tildrakizumab for the 52 weeks.
Nasopharyngitis was the most common adverse event, occurring in 12% vs 21%, respectively.

25. Principal Investigator Commentary
3 important highlights are:
Tildrakizumab, an IL-23 inhibitor, is more effective at controlling the signs and symptoms of psoriasis than etanercept.
A majority of patients with inadequate response to etanercept were able to achieve response (PASI>75 and PGA 0/1) after 3 doses of tildrakizumab over 20 weeks.
Tildrakizumab is an option for patients who are biologic-naïve or who have not had an adequate response to etanercept. Adverse events were similar between the etanercept and tildrakizumab groups.

26. Principal Investigator Commentary (cont)
Impact on current patient management
The blockade of IL-23 with tildrakizumab is an effective and convenient therapy with a good safety profile for our patients with psoriasis.

27. Faculty Commentary
It is exciting to see data on yet another approved drug for psoriasis.
Tildrakizumab is an IL-23 antagonist; blocking the IL-23/IL-17 pathway seems to be the sweet spot for psoriasis management.

28. Implications for Clinical Practice
Impact on current patient management
While etanercept was the first revolutionary biologic for psoriasis, it is also one of the least effective of the tools we now have.
These data tell us that tildrakizumab works when etanercept doesn’t, but that doesn’t change things for us much, as we already have a lot of drugs to use after etanercept, and, given the efficacy and safety of those drugs, we often use them before etanercept.
Impact on future patient management
These results add to our understanding of blocking IL-23 and the IL-23/IL-17 pathway. It’s another block in the wall showing us that this pathway is critical to psoriasis, and that blocking it is an effective and safe way to manage psoriasis.

29. Implications for Clinical Practice (cont)
Unanswered questions
Cost of treatment is still unknown.
Moreover, we still don’t know how tildrakizumab compares to all the other highly effective psoriasis treatments. It’s nice to have options. With the limited data, it can be hard to decide which drug to start with.
But the bottom line is that all the options are very good; we probably don’t go too far wrong with our choice of any of these treatments.

30. Long-term efficacy and safety of ixekizumab for the treatment of moderate-to-severe plaque psoriasis sustained for 3 years: Results of a randomized, controlled phase 3 study (UNCOVER-3) (#6581)

31. Study Design and Methods
The trial included adults with a Psoriasis Area and Severity Index (PASI) score ≥12, affected body surface area (BSA) ≥10%, and static Physician Global Assessment (sPGA) ≥3 at both screening and baseline visits.
Prior treatment with etanercept was not allowed.
At week 0 and through week 12, patients were randomized (2:2:2:1) to receive:
Ixekizumab 160 mg loading dose, then 80 mg every 2 weeks.
Ixekizumab 160 mg loading dose, then 80 mg every 4 weeks.
Etanercept 50 mg twice weekly.
Placebo.
After week 12, all patients received ixekizumab 80 mg every 4 weeks through week 156.
After week 60, the dose could be adjusted to ixekizumab 80 mg every 2 weeks at the investigator’s discretion.

32. Results Summary
1346 adults with a mean age of 46 years; approximately 70% were men.
At baseline,
body surface area affected ranged from 28.0% to 28.6%.
PASI score ranged from 20.7 to 21.2.
sPGA score ranged from 3.5 to 3.6.
Dermatology Life Quality Index score ranged from 11.5 to 12.7.
At week 156,
a PASI 75 score was achieved in 93.7% of observed cases, a PASI 90 in 81.1%, and PASI 100 in 56.1%.
sPGA of 0 or 1 was achieved in 80.4% of observed cases and sPGA of 0 in 56.5%.

33. Results Summary (cont)
86.4% to 88.5% of patients had ≥1 treatment-emergent adverse event.
43.1% to 50.0% were of moderate severity.
A serious adverse event occurred in 10.8% to 19.1%.
Infections remained the most commonly observed adverse events.
Viral upper respiratory tract infection was the most common, occurring in 25.3% to 29.0%.
Grade ≥3 neutropenia was observed in 0% to 1.1%.

34. Faculty Commentary
I am old enough to remember when TNF inhibitors were approved. They were revolutionary. I thought I’d never see another quantum leap forward like that.
Then the IL-17 drugs came along. They are so effective! And they seem to come with very minimal safety baggage. Those of us who care for patients with psoriasis are blessed and spoiled!

35. Implications for Clinical Practice
Impact on current patient management
Based on the mechanism of action of IL-17 inhibition, we don’t expect major safety issues. Perhaps we might expect an increased risk of candidiasis.
Each year of additional safety data gives me more and more confidence that we do fully understand the safety profile of these drugs, and it looks terrific.
Impact on future patient management
Clearly, IL-17 inhibitors will play a major role in the management of patients with moderate-to-severe psoriasis.

36. Implications for Clinical Practice (cont)
Unanswered questions
Longer follow-up will still be nice to have. I feel very confident after 3 years, but I’ll be more totally confident after we see the 5-year outcomes.
The other issue is how well IL-17 antagonism compares to IL-23 blockade. Both seem very effective. Right now, IL-23 blockade seems to require fewer shots and may have less risk of exacerbating bowel disease; but IL-23 blockers are so new, it’s hard to say with any level of certainty.

37. Adverse medical conditions in patients with psoriasis treated with biologic versus conventional systemic therapy: A United States claims-based analysis (#6706)

38. Study Design and Methods
Patients were adults with psoriasis diagnosed on 2 or more dates, one of which was by a dermatologist.
All were biologic-naïve at the index date.
The index date was the date on which first biologic therapy or conventional systemic therapy/topical therapy was initiated.
Two mutually exclusive cohorts were created based on receiving either biologic or conventional systemic therapy/topical treatment. The biologic cohort was stratified into 4 cohorts:
adalimumab, etanercept, ustekinumab or other biologics, ie, a combination of etanercept, ustekinumab and infliximab

39. Study Design and Methods (cont)
Patients were followed until the first occurrence of one of the following:
Initiation of a systemic therapy for psoriasis other than the index treatment.
60 days after index treatment discontinuation.
End of data availability or continuous health plan enrollment.
Studied adverse medical conditions were selected on FDA product labels and postmarketing surveillance registries.
Only incident events based on ICD-9-CM diagnosis code were analyzed.
Multivariate Cox-proportional hazard regression models were used to compare the risk of developing an adverse medical condition between cohorts.

40. Results Summary
42,981 biologic-naïve patients met the inclusion criteria, which included enrollment in their health care plan for ≥12 months prior to and ≥1 month after the index date.
5197 patients were treated with adalimumab, 3311 with etanercept, 1370 with ustekinumab, and 187 with infliximab.
19,666 patients were treated with topical therapy and 13,250 with conventional systemic therapy, including phototherapy, methotrexate, acitretin, or isotretinoin.
The median age in each of the cohorts was:
Adalimumab 46 years; etanercept 46 years; ustekinumab 47 years; conventional systemic therapy/topical 50 years.
The proportion of females was slightly less than 50% in the biologic cohorts and significantly lower than in the conventional systemic therapy/topical cohort (53.1%).
Median study period duration was significantly longer for biologic cohorts than conventional systemic therapy/topical cohort (ranging from 5.3 to 7.9 months vs 3.3 months, respectively).

41. Results Summary (cont)
Among the adverse medical conditions (AMC)
Infection occurred in 28.7% to 41.8%.
Mental disorder in 9.3% to 18.3%.
Abnormal laboratory test result in 6.0% to 10.8%.
Cardiovascular disease in 3.3% to 5.5%.
Malignancy 2.1% to 2.6%.
Respiratory disease 1.9% to 3.7%.
The risk of an AMC was similar or lower in patients treated with a biologic vs conventional systemic therapy/topical therapy.
AMC that were significantly lower with biologic therapy compared to conventional systemic therapy/topical therapy included the risk of
infection with adalimumab, etanercept, and ustekinumab (hazard ratio 0.86 to 0.93).
malignancy with adalimumab (hazard ratio 0.71).
respiratory diseases with etanercept (hazard ratio 0.80).

42. Results Summary (cont)
The risks of AMC were similar between adalimumab and the combination of etanercept, ustekinumab, and infliximab.
Limitations of the study included:
limited follow-up period.
statistical power may have been limited due to the low incidence of some AMC observed.
disease severity may be a potential confounding factor since biologic therapies may be prescribed for patients with more severe psoriasis compared to conventional systemic therapy/topical therapies.
only AMC for which patients sought medical care were analyzed.

43. Principal Investigator Commentary
3 important highlights are:
Among studied AMC
infection was most common across cohorts (28.7% to 41.8%).
mental disorder (9.3% to 18.3%).
abnormal laboratory test result (6.0% to 10.8%).
Biologic therapies were associated with a risk of AMC similar to or lower than conventional systemic therapy/topical therapies among biologic-naïve patients, with fewer infections being the most notable finding.
Impact on current patient management
Not sure, but clinicians should be vigilant for infections despite the findings in this study.

44. Faculty Commentary Biologics are commonly used for psoriasis.
However, <1-of-5 patients eligible for systemic or biologic therapy are receiving systemic or biologic therapy.
Long-term safety data provide reassurance about safety of biologic.
Study results should encourage us to treat more patients with moderate-to-severe psoriasis with biologic therapy.

45. An open-label, observational study evaluating calcipotriene 0
An open-label, observational study evaluating calcipotriene 0.005%/betamethasone dipropionate 0.064% foam in psoriasis patients being treated with biologic agents (#6239)

46. Study Design and Methods
The trial utilized an open-label, single-blind, observational, real-world design.
It involved adults with psoriasis covering ≤5% of their body surface area despite being treated with biologic agents for ≥24 weeks.
All patients received Cal/BD foam once daily for 4 weeks followed by Cal/BD foam on 2 consecutive days every week for an additional 12 weeks.
Cal/BD foam consisted of calcipotriene 0.005% in combination with betamethasone dipropionate 0.064%.

47. Results Summary 25 patients were included:
18 men and 7 women with a mean age of 53 years; 84% were Caucasian.
On average, patients had a 24-year history of psoriasis.
At baseline, 52% were being treated with ustekinumab, 20% adalimumab, 20% secukinumab, and 8% other biologics.
At weeks 4 and 16, average improvements were
63% and 49%, respectively, for Physician Global Assessment (PGA).
59% and 40%, respectively, for body surface area (BSA).
77% and 59%, respectively, for PGA x BSA.

48. Results Summary (cont)
Total clearance of psoriasis occurred by week 4 in 28%.
At baseline, 12% of patients met the treat-to-target goal of BSA ≤1%. At weeks 4 and 16, this increased to 76% and 68%, respectively.
At baseline, 4% of patients had PGA ≤1. At weeks 4 and 16, this increased to 76% and 68%, respectively.
The Dermatology Life Quality Index score improved from 3 at baseline to 1 at both weeks 4 and 16.
Other measures of treatment satisfaction also improved.
There were no treatment-related adverse events or any serious adverse events.

49. Principal Investigator Commentary
3 important highlights are:
Many moderate-to-severe patients with psoriasis even on state-of-the-art biologic therapy for ≥24 weeks still have significant disease activity that warrants either adding therapy, switching to a different biologic, or escalating the dose.
Adding topical therapy with Cal/BD foam once daily was associated with a significant improvement of every measure of disease activity at week 4 and maintained with twice-a-week application through week 16.
The treat-to-target goal (BSA ≈ 1%) was achieved by 3/4 of patients at week 4 and 2/3 of patients at week 16.

50. Principal Investigator Commentary (cont)
Impact on current patient management
Cal/BD foam is an effective, well-tolerated topical agent that significantly improves psoriasis disease management in patients on stable biologic therapy.
As add-on, Cal/BD provides disease control that may prevent or delay switch in patients on stable biologic therapy for moderate-to-severe psoriasis.

51. Faculty Commentary
Biologics are very effective, but do not always provide clear skin. The low DLQI of 3 showed that patients had great responses from their perspective even before the topical was added.
The latest guidelines say the goal should be to get the psoriasis down to ≤1% BSA affected. Adding a topical may be a good way to do that.
The glass is more than half full. In just 4 weeks, 3 of 4 patients achieved ≤1% BSA involved. On the other hand, 1 in 4 didn’t, and 1 in 3 didn’t by week 16.

52. Implications for Clinical Practice
Impact on current patient management
Topicals may be old-fashioned, but they are still useful for helping patients on biologics get more fully clear of their psoriasis.
Impact on future patient management
New biologics keep coming that seem to have higher and higher clearance rates. But despite that, patients often have some residual disease for which topicals will be appropriate.

53. Implications for Clinical Practice (cont)
Unanswered questions
We have to pay close attention to patients’ adherence to treatment. I think the reason this study did not observe continued improvement between week 4 and week 16 is that patients may have become less adherent to their topical treatment over time.
This study only tested one particular topical treatment. Which one is best is not known. I suspect there isn’t one best topical for everyone. Perhaps the best topical is the one that your particular patient wants to use.

54. Impact of withdrawal and retreatment on immunogenicity of guselkumab in patients with moderate-to-severe plaque psoriasis (#6644)

55. Study Design and Methods
Patients with moderate-to-severe psoriasis were randomized (2:1:1) to one of 3 groups:
Group 1: Guselkumab 100 mg at weeks 0, 4, 12, and 20.
Group 2: Placebo at weeks 0, 4, and 12, followed by guselkumab 100 mg at weeks 16 and 20.
Group 3: Adalimumab 80 mg at week 0, 40 mg at week 1, then 40 mg every 2 weeks through week 23.

56. Study Design and Methods (cont)
At week 28,
Psoriasis Area and Severity Index (PASI) 90 responders in group 1 were re-randomized (1:1) to either continue guselkumab every 8 weeks or withdraw from guselkumab.
Withdrawal patients were retreated with guselkumab upon loss of ≥50% of the PASI improvement they had achieved at week 28.
PASI 90 responders in groups 2 and 3 were withdrawn from guselkumab or adalimumab.
Upon loss of ≥50% of the PASI improvement they had achieved at week 28, guselkumab was started/restarted.
PASI 90 nonresponders in all groups continued or started guselkumab.
From week 76 to week 100, all patients received open-label guselkumab 100 mg every 8 weeks.

57. Results Summary
Of the 992 patients in VOYAGE 2, 947 received guselkumab at some point in the trial and had serum samples that were evaluable for antidrug antibodies.
The overall incidence of antidrug antibodies was 8.6%.
Titers were ≤1:160 in 76.5% and ≤1:320 in 90.1%.
The overall incidence of neutralizing antibodies was 0.4%.
The incidence of antidrug antibodies occurring after exposure to guselkumab was 10.2% in those who were withdrawn and retreated with guselkumab compared with 6.8% of those who continued guselkumab.

58. Results Summary (cont)
There was no impact of antidrug antibodies on systemic exposure of guselkumab
between patients who were positive for antidrug antibodies and those who were negative for antidrug antibodies.
before and after development of antidrug antibodies within a patient.
Among the 32 patients withdrawn and retreated with guselkumab who were positive for antidrug antibodies
trough serum concentration of guselkumab recovered to the level achieved prior to withdrawal.
100% achieved IGA score of 0 or 1.
93.8% achieved PASI 90.
2 injections were associated with a mild injection site reaction.
no anaphylactic or serum sickness-like reactions to guselkumab were reported.

59. Faculty Commentary
First, titers of antibodies to drugs doesn’t mean much to me. Every company has their own assay. What numbers we get are just numbers. We can’t compare across drugs, and the percent with antibody may depend totally on how much antibody was considered a positive result. I pretty much ignore rates of antibodies. What matters is the efficacy and safety of the drug.
When at least 9 out of 10 patients are having a great response, antidrug antibody must not be that important.

60. Implications for Clinical Practice
Impact on current patient management
This study showed that even when there was detectable antibody, it didn’t seem to make any difference to the efficacy of the drug.
And when patients stop and restart, the drug should still work.
We may not tell patients to stop and restart, but they may do it anyway; perhaps because of a lapse in insurance, perhaps because they just want to see what would happen if they stop treatment. It’s reassuring to know guselkumab will still work.

61. Implications for Clinical Practice (cont)
Impact on future patient management
With 2 years of great efficacy and safety data, guselkumab is clearly among our really good psoriasis treatments.
I’m also looking forward to seeing us have more IL-23 blocker choices!
Unanswered questions
2 years of data is very good. I’m looking forward to when we have 5 years of efficacy and safety data. I anticipate it will be solid, but we won’t know with certainty until we see it.