During his session, “Which Psoriasis Therapy for Which Patient,” presented at the 2022 Fall Clinical Dermatology Conference, Mark Lebwohl, MD, went over the many treatment options for patients with psoriasis and psoriatic arthritis, and the risks they could pose for these patients.

To start, he looked at all the drugs that are or will soon be approved for psoriasis and psoriatic arthritis. The new ones included bimekizumab, which will hopefully be available soon; deucravacitinib, which has been approved for several weeks; and JAK inhibitors, such as tofacitinib and upadacitinib, now approved for psoriatic arthritis. He also shared that mirikizumab was discontinued for psoriasis, despite its effectiveness.

He noted that there has been a shift for psoriatic arthritis. The usual treatments of choice, such as TNF blockers and IL-17 blockers, may be joined with IL-23 blockers. However, they have not reached the degrees of efficacy seen in IL-17 and TNF blockers. Additionally, data on the JAK inhibitor upadacitinib for psoriatic arthritis is some of the best presented.

Regarding obesity, Dr Lebwohl shared that IL-17 and IL-23 blockers are the treatments of choice whereas for cardiovascular risk factors, recent data showed about a 50% reduction in myocardial infarctions in patients on TNF blockers. However, ustekinumab may be a bit controversial;  several papers have suggested that in the first 6 months after starting ustekinumab, there might even be an increase in cardiovascular risk, yet that is still not clearly established. He added that methotrexate reduces myocardial infarctions, but much less than TNF blockers. He also presented a study that looked at coronary artery plaques in patients on biologics. Patients on TNF blockers displayed a 0.06 millimeter squared reduction over a year in the size of the plaque, meanwhile the IL-17 blockers displayed 0.15.

“It looks like the IL-17s are going to be promising here. The problem is, we don't have enough registry data yet, so it's going to get question mark pluses. But I am pretty confident that these are going to be large green pluses as we have more data,” he stated. He also added that there are no data on the IL-23 blockers even though they reduce inflammation, but he hopes that will be a positive result.

Next, Dr Lebwohl remarked that cyclosporine and acitretin raise lipids that have been associated with a minor increase in myocardial infarctions. He warned that physicians should not be using these drugs in patients who may die soon of a myocardial infarction. Additionally, he avoids TNF blockers in patients with advanced melanomas that may not be cured. He also added that infliximab has a package warning for lung cancer and chronic obstructive pulmonary disease, so it is best to avoid TNF-blockers in patients with uncured lung cancer.

“I would never use a TNF blocker in a patient with a lymphoma, and I'm happy to debate that with anybody,” he stressed.

He moved onto IL-17 and IL-23 inhibitors, starting with ustekinumab. He noted that it has shown a reduction in malignancy—not an increase. He stressed that he does use IL-23 blockers in patients with cancers despite always having a conversation with their oncologist. Additionally, IL-17 blockers showed no reports of malignancy.

Finally, he shared that acitretin is the hidden hero. Despite it not being the best monotherapy for psoriasis, it effectively suppresses malignancies. In fact, it is commonly used to suppress cancers in basal cell nevus syndrome.

“Acitretin is the only one that got a green plus, but I think the 17 and 23 blockers are not far behind it,” he concluded.

Reference
Lebwohl M. Which psoriasis therapy for which patient. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.