Certain Clinical Factors Tied to Poor Response to Biologics for Psoriasis

Certain clinical characteristics were negatively associated with achieving a response to biologic therapies in patients with psoriasis, a meta-analysis showed.

Using data from 31 observational studies, the following factors were negatively associated with achieving Psoriasis Area and Severity Index (PASI) 90 scores at 6 months:

• Previous exposure to biologics: OR 0.44 (95% CI 0.29-0.67)
• Higher body mass index (BMI): OR 0.96 (95% CI 0.94-0.99)
• Previous smoking: OR 0.81 (95% CI 0.67-0.98)
• Current smoking: OR 0.78 (95% CI 0.66-0.91)

However, using data from the included randomized trials, only BMI of 30 or higher was negatively associated with treatment response (PASI 90 at 3 months: OR 0.57, 95% CI 0.48-0.66), reported Christopher Willy Schwarz, MD, of Copenhagen University Hospital – Herlev and Gentofte in Denmark, and colleagues in JAMA Dermatology.

Prior studies have shown that previous exposure to biologics, smoking, and high BMI are negatively associated with the effectiveness of biologics, the authors noted. However, other studies did not find evidence of any associations, and whether there is an association between other clinical characteristics, such as sex, and the effectiveness of biologics remains unclear.

“It is also unclear whether these clinical characteristics have varying effects on the different biologics available for treating psoriasis,” they wrote.

“Studies indicate that patients who switch treatments due to adverse events are at a higher risk for subsequent drug discontinuation,” Schwarz and team noted. “In addition, patients who experience secondary biologic failure are more likely to achieve a response when they switch treatments, as opposed to those who experience primary failure.”

Danilo C. Del Campo, MD, of the Chicago Skin Clinic, told MedPage Today that “in the clinic, we call these ‘tough cases’ of psoriasis.”

“Many patients do great on a biologic, but some don’t respond enough, and you move on to the next biologic. Fortunately, we can usually find the right treatment or combination of treatments to get people under control,” he said.

“Patients with a higher BMI often have a less favorable response to biologic therapies,” he added. “This makes sense because a higher BMI might interfere with how the drug is distributed and metabolized in the body, resulting in less-than-optimal drug levels at standard dosages.”

Steven Daveluy, MD, of Wayne State University in Dearborn, Michigan, noted that “beyond the fact that patients may be underdosed based on their weight, fat cells in our body increase inflammation, including psoriasis. An unhealthy diet — low in fiber, high in saturated fat, high in processed foods — also triggers inflammation in our body.”

Del Campo also pointed out that “smoking is known to worsen psoriasis and reduce treatment effectiveness due to its systemic inflammatory effects. These findings emphasize the importance of incorporating smoking cessation into a comprehensive treatment plan for psoriasis.”

“The study sheds light on the complexity of psoriasis and the need for treatment strategies that are tailored to a wide range of individual patient factors, beyond just the commonly discussed characteristics,” he said.

Overall, the meta-analysis showed no evidence that sex, diabetes, and psoriatic arthritis were associated with treatment response, according to Schwarz and co-authors.

“Surprisingly, psoriatic arthritis, which like prior biologic exposure, suggests more severe disease warranting systemic therapy did not correlate with treatment response,” Shoshana Marmon, MD, PhD, of New York Medical College in Valhalla, told MedPage Today.

For this study, Schwarz and colleagues searched PubMed, Embase, and Web of Science from their inception through April 2022, and included nine randomized trials and 31 observational studies that reported treatment outcomes as PASI 75 or PASI 90 after 12, 26, and/or 52 weeks of treatment.

The small number of studies prevented subgroup analyses “to investigate whether the clinical characteristics affected the various biologics differently,” the authors noted.

They also acknowledged other limitations to the study, such as the exclusion of some relevant studies that reported reduction in body surface area instead of reduction in PASI.

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