Psoriasis keeps coming back and can't be controlled? It's really not advisable to take biologics on and off

Introduction

The intermittent treatment of psoriasis patients with biologics is not conducive to long-term control of the disease and can easily lead to recurrence or even aggravation of psoriasis symptoms. As psoriasis treatment enters the "biologics era", clinical experts recommend that patients who meet the indications can use biologics with definite efficacy, safety and economy, such as the original adalimumab, for long-term maintenance treatment to achieve controllable and manageable psoriasis.

Long-term standardized treatment with biological agents is better than intermittent treatment. Psoriasis is an immune-mediated, recurrent chronic inflammatory skin disease that cannot be cured. Although it is difficult for patients to accept psychologically, it is indeed a chronic disease that requires lifelong control, just like the diabetes and hypertension we are familiar with. Therefore, the "Guidelines for the Treatment of Psoriasis in China" (2018 edition) also recommends that patients need to "maintain treatment to achieve 'long-term remission' or even 'full control'."

Most psoriasis patients only know that biological agents are "effective" and "quickly effective". Once the symptoms are alleviated, they often stop taking the drugs on their own because they cannot afford the economic burden of long-term treatment due to the high prices. In fact, the inflammatory response in the body has not been completely controlled at this time, so the disease will relapse quickly after stopping the drug. After repeated cycles of "stopping the drug and relapse", the patient's condition becomes worse and he "misunderstands" the biological agents.

Zong Wenkai, chief physician of the Dermatology Hospital of the Chinese Academy of Medical Sciences, emphasized that for moderate and severe patients, it is not recommended to stop the medication or take interval treatment after starting to use biological agents, otherwise it is easy to relapse, resulting in reduced efficacy and increased risk of anti-antibody production. Only after the patient has maintained complete or almost complete clinical clearance for a long time, the dosing interval can be gradually extended or the dosage can be reduced until the medication is stopped according to the patient's specific situation. During this period, the patient's condition and adverse drug reactions should be closely observed.

In fact, data show that all current biological agents, including tumor necrosis factor α (TNF-α) inhibitors, interleukin IL-17 or IL-23 inhibitors, may cause recurrence after discontinuation of medication. Therefore, long-term standardized treatment with biological agents is better than intermittent treatment.

The vicious cycle of stopping medication and relapse gradually "destroys" the patient's physical and mental health. Why is psoriasis so prone to relapse? Experts explain that once psoriasis lesions appear, they can be understood as irreversible. At the site of lesions, tissue-resident memory T cells (TRM) form site-specific disease memory. Once treatment is terminated, the original site of the disease can easily be awakened, leading to relapse. In addition, the inflammatory response at the site of the disease cannot be controlled and eliminated in the short term. Once the medication is stopped, the inflammation will "revive." [1]

It has been clinically proven that the recurrence or rebound of psoriasis will form new, more severe and more extensive attacks, which can change the subtype of the disease, causing moderate psoriasis to turn into severe psoriasis or other serious types.

Authoritative research also shows[2] that if long-term treatment is not adhered to, repeated attacks of psoriasis will further worsen the patient's disease condition and quality of life, greatly increasing the patient's medical and socioeconomic burden, while also significantly increasing the risk of depression, anxiety, and suicidal tendencies.

Therefore, according to the guidance of the treatment goals of the "Guidelines for the Treatment of Psoriasis in China", patients with more severe disease symptoms or psoriasis in special areas should be given individualized treatment plans and continue with standardized treatment. Do not change or stop medication easily.

The long-term use of biologics should consider three factors: efficacy, safety, and economy of the drug. The "Chinese Expert Consensus on Biologic Therapy for Psoriasis (2019)" recommends that patients in the following situations should actively choose to take biologics and use them for a long time:

① When traditional treatment is ineffective, ineffective or intolerant, and the disease has developed into moderate to severe plaque psoriasis;

② When the disease has a significant impact on the quality of life or brings significant health risks;

③ Patients with arthritis-type psoriasis with clear joint symptoms who cannot be effectively relieved by anti-rheumatic drugs, or when the spine and sacroiliac joints are affected.

Professor Zong Wenkai pointed out that when the above-mentioned patients choose a biological agent as a long-term standard drug, they should mainly consider three aspects, namely whether the treatment method is effective in the long term, whether it can guarantee long-term safety, and whether it is sustainable for the patient.

Taking the most common original research adalimumab-Humira as an example, its long-term treatment advantages are relatively clear:

First, the data from the 7-year follow-up showed that the PASI response rate of the original adalimumab was higher than that of etanercept and infliximab, and more patients were able to receive its long-term maintenance treatment [3], [4]; in terms of drug retention rate, the original adalimumab was also superior to etanercept and infliximab [5]; in addition, during the 10-year follow-up, 57-71% of patients were able to achieve an overall assessment of skin lesions as "clear" or "mild" [6]. Overall, the original adalimumab is more effective in long-term treatment.

Secondly, the 10-year follow-up also showed that the incidence of adverse events and serious adverse events of the original adalimumab remained stable, and the incidence of cardiovascular events continued to remain at a low level, proving that its safety is also guaranteed in the long term. [7]

Finally, the original adalimumab-Humira has been included in the national medical insurance, and the treatment cost is low, making long-term treatment a reality. Taking Beijing as an example, as a Class B drug, the medical insurance reimburses 70% and the patient pays 30%. If two bottles are used per month, the monthly out-of-pocket cost is less than 1,000 yuan. (Patients in other regions need to refer to the local medical insurance policy of the patient)

Professor Zong Wenkai also pointed out that before using biological agents, the patient's health status should be fully evaluated, and the risks of tumors, active infections, tuberculosis, hepatitis and other diseases should be excluded. During the treatment, blood routine, ANA, CRP, liver and kidney function, viral hepatitis-related indicators, T-SPOT (or PPD test), chest X-ray (or chest CT) and other tests should be regularly checked, and the test results should be dynamically followed up and evaluated. Long-term and standardized use of biological agents by patients can make psoriasis controllable and manageable.

References:

[1] Carey, Wayne, et al. "Relapse, rebound, and psoriasis adverse events: An advisory group report." Journal of the American Academy of Dermatology 54.4-supp-S(2006):S171-S181.

Yi Meihui et al. Advances in immunological research related to psoriasis relapse[J]. Journal of Dermatology and Venereology, 2019, 26(01):59-62.

[2] Yang Ying et al. Maintenance treatment of moderate to severe psoriasis[J]. Chinese Journal of Dermatology, 2014, 47(009):682-684. [1] Potenza MC et al. Dermatol Ther. 2018;31:e12565

[3] Potenza MC et al. Dermatol Ther. 2018;31:e12565

[4] Potenza MC et al. Dermatol Ther. 2018;31:e12565

[5] Egeberg A, et al. Br J Dermatol. 2018 Feb;178(2):509-519.

[6] Thaci D et al. Presented at the 28th European Academy of Dermatology and Venereology (EADV) Congress, 9–13 October 2019, Madrid, Spain

[7] Thaci D et al. Presented at the 28th European Academy of Dermatology and Venereology (EADV) Congress, 9–13 October 2019, Madrid, Spain