Original ArticleDoes the treatment ladder for systemic therapy in moderate to severe psoriasis only go up? The percentage of patients with severe psoriasis on biologics increases over timeEscalera terapéutica en la psoriasis moderada y grave ¿ Sólo hacia arriba?: El porcentaje de pacientes con psoriasis grave tratados con biológicos se incrementa con el tiempo
Introduction
The introduction of biologic therapy has changed the management of moderate to severe psoriasis, with these agents now representing the highest rung of the therapeutic ladder that starts with topical treatments and phototherapy.1 However, we do not know whether, in clinical practice, this therapeutic progression is always unidirectional and progressive or whether biologic therapy will eventually become just another option in the rotational strategies used, with patients switching back and forth between biologic therapy and classic treatments. The answer to this question is important because of its relevance to safety (in terms of cumulative exposure), efficacy (which may be affected by immunogenicity induced by intermittent use), and cost of treatment.2, 3
We report on the switch from classic to biologic drugs and vice versa during the specified follow-up period in a cohort of patients with psoriasis.
Section snippets
Materials and methods
BIOBADADERM is a prospective cohort of patients with moderate to severe psoriasis receiving systemic therapy. Patients from 12 Spanish hospitals have been enrolled in the cohort since 2008. The present study is based on data from patients enrolled before the end of October 2013. A more detailed description of 632 patients from this cohort has been published elsewhere.4 Patients are included when they are first prescribed any specific conventional or biologic systemic treatment, and they are
Results
The proportion of patients receiving biologic and nonbiologic treatment varies over time. In total, 47.3% of the patients (926/1956) were prescribed a classic systemic treatment and 52.7% (1030/1956) a biologic agent on entry into the study. Of the 741 patients who accumulated 5 years of follow-up, 21.9% (155) were receiving nonbiologic drugs and 78.1% (553) were on biologic therapy on the first day of their 5th year of follow-up (Table 1).
As the length of follow-up increased, so did the
Discussion
In the BIOBADADERM cohort, patients with moderate to severe psoriasis on systemic treatment with classic or biologic drugs were frequently switched from one treatment to another. We observed that the proportion of patients receiving biologic therapy increased with longer follow-up, whereas the percentage of patients on classic treatment decreased over time. As the severity of psoriasis can vary over time in any given patient, this finding may indicate a tendency among dermatologists to
Funding sources
The BIOBADADERM project is financed by the Fundación Academia Española de Dermatología y Venereología (FAEDV), which receives support from the Spanish Medicines and Health Products Agency (AEMPS) and from pharmaceutical companies (Abbott, PfizerMSD and Janssen). Role of the Sponsors: The FAEDV provided administrative support and the AEMPS reviewed the study protocol. Apart from these contributions, none of the sponsors participated in the design or conduct of the study, in the collection,
Protection of human and animal subjects
The authors declare that no experiments were performed on humans or animals for this investigation.
Confidentiality of data
The authors declare that they have followed the protocols of their work center on the publication of patient data.
Right to privacy and informed consent
The authors must have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence must be in possession of this document.
Conflicts of interest
Dr Carrascosa served as a consultant and participated in speakers’ bureaus for Abbvie Laboratories, Janssen Pharmaceuticals Inc., MSD, Pfizer-Wyeth, Lilly, Novartis and Celgene. Dr Carretero served as a consultant for Abbott Laboratories, Janssen-Cilag Pty Limited, MSD, and Pfizer Inc.; gave expert testimony for Abbott Laboratories, MSD, and Pfizer Inc.; received grants from Abbott Laboratories, Janssen Pharmaceuticals Inc., MSD, and Pfizer Inc. and equipment from MSD and Pfizer Inc. Dr
Acknowledgments
The authors wish to thank all the participating hospitals, especially the dermatologists and collaborators who participated in the creation of BIOBADADERM, for their dedication, effort and enthusiasm in this project. BIOBADADERM Study Group Members: Cristina Carazo, José Bañuls, Juan Francisco Silvestre, Pilar Albares, Isabel Betlloch, Monserrat Hernández, Diana Ruiz-Genao, Almudena Nuño, Patricia Guillem, Begoña Echeverría, Esther Margarit, Carlos Muñoz-Santos, Sara Pedregosa, Lara Ferrándiz,
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