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Will the Future Route for Systemic Psoriasis Therapy Be Intravenous?

Antitumor necrosis factor- therapy appears to be effective for psoriasis (see JW Dermatology Apr 2001, p.33, and Lancet 2000; 357:385). Prior studies were observational or their results were confounded by concomitant therapies. These investigators conducted a double-blind, placebo-controlled, partially manufacturer-supported trial of infliximab as monotherapy for plaque-type psoriasis. Thirty-three patients were randomly assigned to 3 treatment regimens and were followed for a total of 10 weeks. At weeks 0, 2, and 6 they received intravenous placebo or 5 mg/kg or 10 mg/kg of intravenous infliximab. One patient in each group withdrew from the study; their outcomes were considered nonresponse.

At 10 weeks, Physician's Global Assessment (PGA) and PASI scores were used to assess response to treatment. PGA scores were "excellent," "good," or "clear" in 9 of 11 patients who received 5 mg/kg of infliximab; in 10 of 11 who received 10 mg/kg; but in only 2 of 11 patients who received placebo. All 9 responders in the 5-mg/kg group were rated "excellent" or "clear," whereas three 10 mg/kg responders were rated "good." Similarly, PASI scores improved by more than 75 percent in 9 patients who received 5 mg/kg; 8 who received 10 mg/kg; and 2 who received placebo. Responses endured for at least 4 weeks after treatment. Adverse events were relatively minor: seven 10-mg/kg patients experienced headache, versus two placebo patients and one 5-mg/kg patient. Two 5-mg/kg patients had positive antinuclear antibody tests at 10 weeks. The authors note that response to therapy was rapid and comparable to the response to cyclosporin.

Comment: The authors conclude that TNF- is involved in the pathogenesis of psoriasis and that infliximab is efficacious as a monotherapy for psoriasis. Several other biological agents that target T-cell activation, cytokine expression, and lymphocyte trafficking are being studied. Many agents are administered by injection (often intravenously), which is inconvenient for dermatologists who practice in office-based settings. However, infusion companies in metropolitan areas can instruct patients to use these techniques. Once-monthly therapy, such as infliximab, is not too inconvenient and takes roughly 2 hours to administer. This agent is expensive, though ($1250 to $1500 per treatment), and the literature suggests that antibodies may develop, affecting long-term effectiveness. Although efficacious and rapid in its onset of action, intravenous infliximab may be an unacceptable option for many patients because of the IV delivery and the development of antibodies. It is likely to be only one of the breakthroughs that emerge as the pathogenesis of psoriasis becomes better understood.

— JP Callen

Published in Journal Watch Dermatology July 17, 2001

Citation(s):

Chaudhari U et al. Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: A randomised trial. Lancet 2001 Jun 9 357 1842-1847.

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