What are clinical practice guidelines on biologic therapy for psoriasis?

Updated: Mar 17, 2021
  • Author: Jacquiline Habashy, DO, MSc; Chief Editor: William D James, MD  more...
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Guidelines on psoriasis biologic therapy from the British Association of Dermatologists  [59]

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

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

Guidelines on the management and treatment of psoriasis with biologics by the American Academy of Dermatology and the National Psoriasis Foundation  [60]

TNF-alpha Inhibitors

Etanercept recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 50 mg; self-administered SC injection twice weekly for 12 consecutive weeks

  • Recommended maintenance dose of 50 mg once weekly; 50 mg twice weekly is more efficacious than once weekly and may be required for better disease control in some patients

  • Recommended as monotherapy option in adults with moderate-to-severe plaque psoriasis affecting the scalp or nails

  • Can be recommended as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • Recommended combination treatment option with methotrexate for moderate-to-severe plaque psoriasis in adults

  • May be combined with acitretin, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Infliximab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose is an infusion of 5 mg/kg administered at week 0, week 2, and week 6; thereafter, administered every 8 weeks

  • Recommended to be administered at more frequent intervals (less than q8wk and as frequently as q4wk during maintenance phase) and/or at a higher dose (up to 10 mg/kg) for better disease control in some adults

  • Recommended as monotherapy option for moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp in adults

  • Can be recommended as monotherapy option in adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis; it also inhibits radiographically detected joint damage in psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, or apremilast for moderate-to-severe plaque psoriasis in adults

Adalimumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 80 mg taken as two self-administered SC 40-mg injections, followed by a 40-mg self-administered SC injection 1 week later, followed by 40-mg self-administered SC injections every 2 weeks thereafter

  • Maintenance dose of 40 mg/wk recommended for better disease control in some patients

  • Recommended as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (palmoplantar psoriasis), nails, or scalp

  • Can be recommended as monotherapy option for adults patients with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Certolizumab has been approved by the FDA for the treatment of plaque psoriasis, psoriatic arthritis, Crohn disease, ankylosing spondylitis, and rheumatoid arthritis. Approved dosing for moderate-to-severe psoriasis is 400 mg (two 200-mg SC injections) every other week. It is likely to possess class characteristics similar to those of other TNF-alpha inhibitors.

Interleukin-12/23 Inhibitors

Ustekinumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting doses: (1) patients weighing 100 kg or less, 45 mg SC initially and 4 weeks later, followed by 45 mg administered SC every 12 weeks; (2) patients weighing more than 100 kg, 90 mg administered SC initially and 4 weeks later, followed by 90 mg administered SC every 12weeks

  • Recommended alternate dosages are higher doses (90 mg instead of 45 mg in patients weighing ≥100 kg) or with greater frequency (eg, every 8 wk in maintenance phase) if response to standard dosing is inadequate

  • Can be used as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp

  • Can be used as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis; evidence is limited for use in inverse and guttate psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Interleukin-17 Inhibitors

Secukinumab recommendations are as follows:

  • Monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 300 mg by self-administered SC injection at week 0, week 1, week 2, week 3, and week 4, followed by 300 mg every 4 weeks

  • Recommended maintenance dose of 300 mg every 4 weeks

  • Recommended dose of 300 mg is more effective than 150 mg

  • Can be recommended as monotherapy in adults with moderate-to-severe plaque psoriasis affecting the head and neck (including the scalp) or nails

  • Recommended as monotherapy option in adults with moderate-to-severe palmoplantar plaque psoriasis

  • Can be recommended as monotherapy option in adults with moderate-to-severe palmoplantar pustulosis

  • Can be used as monotherapy in adults with erythrodermic psoriasis

  • May be used as monotherapy in adults with plaque psoriasis when associated with psoriatic arthritis

Ixekizumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 160 mg by self-administered SC injection, followed by 80 mg at week 2, week 4, week 6, week 8, week 10, and week 12

  • Recommended maintenance dose of 80 mg every 4 weeks

  • Can be recommended as monotherapy option in adults with moderate-to-severe plaque psoriasis affecting the scalp or nails

  • Can be recommended as monotherapy option in adults with erythrodermic psoriasis or generalized pustular psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis when associated with psoriatic arthritis

Brodalumab recommendations are as follows:

  • Recommended as monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Can be used as monotherapy option in adults with generalized pustular psoriasis

  • Recommended dose of 210 mg by self-administered SC injection at week 0, week 1, and week 2, followed by 210 mg every 2 weeks

Interleukin-23 Inhibitors

Guselkumab recommendations are as follows:

  • Recommended as monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended dose of 100 mg by self-administered SC injection at week 0 and week 4, followed by every 8 weeks thereafter

  • Recommended as monotherapy option in adults with scalp, nail, or plaque-type palmoplantar psoriasis

Tildrakizumab recommendations are as follows:

  • Recommended as monotherapy treatment option in adults with moderate-to-severe plaque psoriasis

  • Recommended dose of 100 mg given in office by physician-administered SC injection at week 0 and week 4, followed by every 12 weeks thereafter

Risankizumab is not approved by the FDA, but it can be used as monotherapy in adults with moderate-to-severe plaque psoriasis. When approved, the dose will likely be 150 mg given by self-administered subcutaneous injections at week 0 and week 4, followed by every 12 weeks.


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