Perspective from Allan Gibofsky, MD, JD
Disclosures: Meer reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
October 25, 2021
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Biologic use in psoriasis may increase PsA incidence vs. phototherapy, oral therapies

Perspective from Allan Gibofsky, MD, JD
Disclosures: Meer reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Patients with psoriasis who use biologics are more likely to develop psoriatic arthritis than those on other or no therapies, according to retrospective data published in the Annals of the Rheumatic Diseases.

“Given the shared pathogenetic pathways (tumor necrosis factor (TNF), IL-17), one would expect the treatment of psoriasis to be associated with reduced progression to clinically overt PsA,” Elana Meer, an MD/MBA candidate at the University of Pennsylvania, in Philadelphia, and colleagues wrote. “Furthermore, biologics, such as TNF alpha inhibitors, IL17i, 12/23i and IL23i, have demonstrated a clear benefit in improving the signs and symptoms of both psoriasis and PsA.”

Patients with psoriasis who use biologics are more likely to develop PsA than those on other or no therapies, according to data derived from Meer E, et al. Ann Rheum Dis. 2021;doi:10.1136/annrheumdis-2021-220761.

“However, the relationship between a treatment for psoriasis and resulting PsA may be confusing in that some biologic therapies and retinoids have been purported to result in altered stimulation of the immune system, which has led to the paradoxical onset of PsA or the onset of pustular psoriasis among TNF inhibitor (TNFi) users,” they added. “Studies addressing the impact of therapy for psoriasis on development of PsA are lacking.”

To analyze the link between the use of biologic therapy in patients with psoriasis and the development of PsA, Meer and colleagues conducted a retrospective cohort study of the OptumInsights Electronic Health Record Database. According to the researchers, OptumInsights is a longitudinal database of electronic health records from dozens of health care organizations, including more than 150,000 providers, 2,000 hospitals and 7,000 clinics.

Focusing on the period between 2006 and 2017, the researchers included 193,709 patients with psoriasis without PsA, between the ages of 16 and 90 years, who started either oral or biologic drugs, or phototherapy. Meer and colleagues then determined the incidence of PsA within each therapy group. The analysis included multivariate Cox models to calculate hazard ratios for biologic versus oral or phototherapy, using biologics as a time-varying exposure and in a propensity score-matched cohort.

Among the included patients, 14,569 were using biologics while a combined 20,321 were receiving either oral or phototherapy. According to the researchers, PsA incidence, regardless of therapy exposure, was 9.75 per 1,000 person-years, compared with 77.26 among biologic users, 61.99 among oral therapy users, 26.11 among phototherapy users and 5.85 among those not receiving any of the target therapies.

After multivariable adjustment with time-varying exposure, the adjusted hazard ratio for biologic users was 4.48 (95% CI, 4.23-4.75), compared with those who received oral or phototherapy. After propensity score matching, the hazard ratio for the biologics group was 2.14 (95% CI, 2-2.28) compared with the other therapies.

“In this retrospective cohort study, patients with psoriasis initiating biologic therapy were more likely to develop PsA than patients initiating phototherapy or oral therapies or those not receiving therapy,” Meer and colleagues wrote. “Caution should be used in interpreting retrospective studies of the impact of biologic therapy on development of PsA. Future randomized controlled trials with long-term follow-up are needed to address the impact of therapy for psoriasis on the prevention of and/or the delay in development of PsA.”