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When to Choose Anti-TNF Inhibitors as First-Line Therapies

Although many therapies are associated with better Psoriasis Area and Severity Index (PASI) scores than anti-tumor necrosis factor (anti-TNF) inhibitors, they may still be indicated as first-line therapies for psoriasis among certain patient populations, said Erin E. Boh, MD, PhD, at the 2019 American Academy of Dermatology Summer Meeting.

Drugs like etanercept, infliximab, adalimumab, and certolizumab, among others, are advantageous for a number of reasons. They have reliable long-term safety and efficacy data for numerous populations, indications across multiple disease states, and many years of experience in the treatment of psoriasis, Dr Boh explained.

Numerous factors come into play when choosing a systemic therapy for certain patients, she continued, including:

  • Body surface area
  • Quality-of-life issues
  • Previous therapies and responses
  • Treatment failures
  • Comorbidities
  • Special populations

When it comes to selecting anti-TNF inhibitors as first-line therapies, populations often excluded from trials, such as pregnant women, children, elderly patients, patients with HIV infection, patients with hepatitis C virus (HCV) infection, and Medicare beneficiaries, could benefit most, she explained.

For women who are pregnant or of childbearing age, certolizumab is a good choice. Research has shown that certolizumab has minimal to no transfer through the placental border or into breast milk. As a result, pregnant and breastfeeding women do not need to cease treatment with this drug, said Dr Boh.

Because data on the safety and efficacy of anti-TNF inhibitors is robust, these drugs are likely very safe in children and elderly patients. For pediatric patients in particular, etanercept, adalimumab, and infliximab may be good options to choose.

Some data have suggested that anti-TNF inhibitors are safe for use in patients with HIV infection, especially those with rheumatic diseases. However, anti-TNF inhibitors are currently not FDA-approved for this indication, so caution and monitoring are warranted in this patient population, Dr Boh noted.

Data have also indicated that anti-TNF inhibitors likely do not worsen HCV infection, especially when HCV is treated.

Infliximab can be a very useful option for Medicare beneficiaries or any patients with insurance issues, especially if treatment options are limited, Dr Boh added.

Patients with comorbidities such as arthritis, inflammatory bowel disease (IBD), or hidradenitis suppurativa (HS) could also benefit from anti-TNF inhibitors, especially adalimumab, infliximab, and certolizumab in the context of IBD, and adalimumab and infliximab in the context of HS, she said.

—Christina Vogt


Boh E. Psoriasis treatments: TNF inhibitors with special indications (peds, pregnancy). Psoriasis. Presented at: 2019 American Academy of Dermatology Summer Meeting; July 25, 2019; New York, NY.

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