Mark Lebwohl, MD, Waldman Professor of Dermatology at the Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.
When considering treatments for psoriasis, one has to take into account many different factors about the patient, including age, pregnancy status, weight, and whether there is another condition present. Despite the availability of several new systemic agents for psoriasis treatment, choosing the right therapy in certain patient populations can be challenging. There are few up-to-date reviews on systemic drugs for moderate to severe psoriasis in patients with concomitant chronic illnesses, such as congestive heart failure, or chronic infections, such as hepatitis, HIV, and latent tuberculosis (TB).1
Mark Lebwohl, MD, Waldman Professor of Dermatology at the Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City, spoke at the 77th Annual Meeting of the American Academy of Dermatology about how to choose the best psoriasis treatment for an individual patient based on several considerations. His presentation outlined which medication is best based on individual patient needs and how researchers are now keeping track of this information. He created an organizational schema for doing so (Table).1
Congestive Heart Failure
Comorbidities Dr Lebwohl noted during his presentation included congestive heart failure, latent TB, and HIV infection. Advanced congestive heart failure appears as a contraindication to infliximab (Remicade). “That was based on a study with a thought that infliximab would improve congestive heart failure,” Dr Lebwohl said. “But in fact, the infliximab 10 mg/kg group had more hospitalizations or deaths than the placebo group in this study. Now, at 5 mg/kg, there were not more hospitalizations and deaths. But at the 10-mg dose, there clearly were. It was 18% at week 14, and 27% at week 28.”2
Based on recent research, the rate of heart attacks is dramatically reduced—by about half—following treatment with tumor necrosis factor (TNF) blockers, Dr Lebwohl said. One study suggested that secukinumab (Cosentyx) might have a beneficial effect on cardiac risk by demonstrating an improvement in flow-mediated dilation in patients with psoriasis.3 “So that drug, and all of the other IL-17 and IL-23 blockers, can be used in patients with congestive heart failure,” Dr Lebwohl added.
Another comorbidity, TB, may also have cardiac implications. In patients with psoriasis who are on TNF blockers, TB is commonly extrapulmonary.4 Because patients who are exposed to TB will test positive for the disease for the rest of their lives, it can be difficult for a doctor determine if the patient has been re-exposed, and even a chest x-ray may not be conclusive. For this reason, Dr Lebwohl said, “All medication package inserts warn about TB, and suggest testing for TB prior to starting those drugs. That’s true for infliximab, adalimumab (Humira), etanercept (Enbrel), and certolizumab (Cimzia).”
The package insert for etanercept, which appears to have the lowest risk, does warn about TB, and states that patients need to be evaluated for latent or active TB. Tuberculin skin tests or serologic tests for TB exposure should be performed both before and during treatment. That said, there have been cases of TB that have occurred in patients on etanercept, so it is recommended that patients who have a positive TB test should be treated with prophylaxis regimens for latent TB. In patients who are positive for latent TB or have active TB, the recommendation is to start anti-TB therapy first before starting a biologic.
“There are also patients who test negative for latent TB and then develop active TB,” said Dr Lebwohl. “The TNF blockers can be used in patients who receive TB prophylaxis.” But the downside, he added, is that if they are re-exposed, or develop new TB, it is going to be much harder to find, because TB tests remain positive.
Experts have made the following conclusions about treating psoriasis in patients with latent TB:
- It is safe to use IL-17 inhibitors and apremilast (Otzela) in patients with latent tuberculosis infection (LTBI).
- TNF-alpha inhibitors and ustekinumab (Stelara) can be used only after TB prophylaxis has been initiated for at least 1 month.
- Additional safety data are needed for IL-23 inhibitors, but these will likely be safe.
- Methotrexate and cyclosporine can be used in patients with LTBI after TB prophylaxis.
- Acitretin is safe to use in this setting.
HIV Positive Status
Finally, Dr Lebwohl shared brief insight into psoriasis treatments with people who are HIV positive. There are a few case reports of drugs such as infliximab, adalimumab, or etanercept being used for HIV-positive patients. Many review articles, however, show that HIV has no impact on the effectiveness of biologic therapies, and biologics do not affect HIV viral loads.5 For example, viral loads are not affected by the use of ustekinumab in patients with psoriasis and HIV.
Physicians should be cautious when prescribing immunosuppressive medications, specifically methotrexate, when treating an HIV-positive patient. In one study of treatment with methotrexate in patients who had HIV, two of three patients did not develop opportunistic infections.6
1. Lebwohl M. Psoriasis: which drug for which patient? Presented at: 77th Annual Meeting of the American Academy of Dermatology. March 1-5, 2019. Washington, DC.
2. Chung ES, Packer M, Lo KH, et al. Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial. Circulation.2003;107(25):3133-3140.
3. von Stebut E, Reich K, Thaçi D, et al. Impact of secukinumab on endothelial dysfunction and other cardiovascular disease parameters in psoriasis patients over 52 weeks. J Invest Dermatol. 2019;139(5):1054-1062.
4. Harris J, Keane J. How tumour necrosis factor blockers interfere with tuberculosis immunity. Clin Exp Immunol. 2010;161(1):1-9. doi:10.1111/j.1365-2249.2010.04146.x
5. Menon K, Van Voorhees AS, Bebo BF Jr, et al; National Psoriasis Foundation. Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2010;62(2):291-299. doi:10.1016/j.jaad.2009.03.047
6. Duvic M, Johnson TM, Rapini RP, Freese T, Brewton G, Rios A. Acquired immunodeficiency syndrome-associated psoriasis and Reiter’s syndrome. Arch Dermatol. 1987;123(12):1622-1632.
7. Kaushik SB, Lebwohl MG. Psoriasis: which therapy for which patient: focus on special populations and chronic infections. J Am Acad Dermatol. 2019;80(1):43-53. doi:10.1016/j.jaad.2018.06.056
8. Kaushik SB, Lebwohl MG. Psoriasis: focus on special populations and chronic infections. J Am Acad Dermatol. 2019;80:43-53. doi:10.1016/j.jaad.2018.06.056.