Biologic Therapy for Psoriasis: BAD 2020 Guidelines

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.

Contraindications to Biologic Therapies

• Do not use TNF antagonists in people with demyelinating diseases and consider alternative interventions in people who have a first‐degree relative with demyelinating disease.
• Stop treatment and seek specialist advice if neurological symptoms suggestive of demyelinating disease develop during TNF antagonist therapy. Symptoms include loss or reduction of vision in one eye with painful eye movements; double vision; ascending sensory disturbance and/or weakness; problems with balance, unsteadiness or clumsiness; altered sensation travelling down the back and sometimes into the limbs when bending the neck forwards (Lhermitte symptom).
• Avoid TNF antagonist therapy in people with severe cardiac failure [New York Heart Association (NYHA) class III and IV].
• Stop TNF antagonist therapy in the event of new or worsening pre‐existing heart failure and seek specialist advice.
• Exercise caution and consult a gastroenterology specialist before using brodalumab, ixekizumab or secukinumab in people with inflammatory bowel disease.

"British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update," is published in the British Journal of Dermatology. 

DOI: https://onlinelibrary.wiley.com/doi/10.1111/bjd.19039