Combination Therapy of Biologics With Traditional Agents in Psoriasis

Lyn C. Guenther, MD, FRCPC


Skin Therapy Letter. 2011;16(6) 

In This Article

Combination Therapy With Etanercept (Enbrel®)


The addition of calcipotriol cream twice daily for 4 weeks, then once daily for 8 weeks, in patients with psoriasis and psoriatic arthritis who had not achieved PASI 50 at week 12 (n=45 patients) with etanercept 50 mg twice weekly, allowed 31.1% (14 patients) to become PASI 75 responders and 51.1% (23 patients) to become PASI 50 responders at week 24 despite a dose reduction in etanercept to 25 mg twice weekly at week 12.[21]


Narrowband UVB enhances efficacy irrespective of whether it is used from the start (12 week PASI 75 in 90% vs. 40% on etanercept 25 mg twice weekly monotherapy)[22] or added after 6 weeks to patients who had not attained PASI 75 response with etanercept 50 mg twice weekly (after 6 weeks of combination therapy: mean PASI=1.6 vs. 4.7 for non-UVB treated body half, p=0.0192).


In the EASE trial, the odds ratio of a 'clear'/'almost clear' PGA was 2.246 (95% confidence interval (CI) 1.25, 4.0; p=0.0069) for concomitant methotrexate/etanercept when compared with etanercept monotherapy.[23] In this study, 30% of patients could reduce their weekly dose of methotrexate and 16% could stop it altogether. In the EDUCATE study, 29% could discontinue methotrexate and 7% could lower their dose.[24] In cases of inadequate response to methotrexate, in one study continuation of the methotrexate when etanercept was initiated resulted in greater efficacy with a similar safety profile than when the methotrexate was tapered and discontinued during the first 4 weeks (PGA 'clear' or 'almost clear' at 24 weeks in 66.7% vs. 37.0% respectively, p=0.025).[25]


A small study (n=60) showed that etanercept 25 mg twice weekly and etanercept 25 mg once weekly + acitretin 0.4 mg/kg/day had similar efficacy at week 24 (PASI 75: 45% and 44% respectively; mean BSA reduction: 80% and 78.2% respectively), suggesting that concomitant use of acitretin can lower the required dose of etanercept.[26]


Small case series suggest that etanercept can maintain control when cyclosporine discontinuation is needed.[23,27] In a small psoriatic arthritis study, addition of cyclosporine 3.0 mg/kg/day to 11 patients whose arthritis was in remission, but who had an insufficient skin response, resulted in 9/11 achieving PASI 75 at week 24.[28]


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