Choosing the Best Biologic for Your Psoriasis

There are three main classes of biologic drugs for psoriasis: the ones that block a chemical called TNF-alpha such as Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab), the one that blocks both T-cell activation and the movement of T-cells into the skin Raptiva (efalizumab), and the one that decreases the number of activated T-cells available called Amevive (alefacept).

Arthritis

The TNF-alpha blocking drugs have the advantage of also treating psoriatic arthritis. The other types of biologics are not helpful in this regard, in fact Raptiva may worsen a patient’s arthritis in some cases.

Staying power

Some patients notice a diminution of the effectiveness of TNF-alpha blocking drugs over months to years. Raptiva apparently keeps working well for patients over several years without losing its effectiveness.

Convenience

The way that each drug is given varies and may play a role in deciding which one is best for you. Amevive is given once weekly for 12 weeks after which (for some patients) no further treatment may be needed for up to a year. Because Amevive is an intramuscular injection, it's typically done in the doctors office although some patients are can give themself the drug. Humira is given once every other week, Enbrel once or twice weekly and Raptiva once weekly and all of these are easy sub-cutaneous (shallow) self-administered drugs, much like insulin. The drugs (except Amevive) need to be refrigerated, which must be kept in mind for those patients who travel frequently. Remicade is given as an IV infusion in a doctor's office.

Special Benefits

Raptiva is the only weight-based biologic. In other words, heavier patients are injected with more drug. The other biologics listed here are dosed on a one-size-fits-all basis. For this reason, heavier patients may in fact be under dosed. This is an important consideration in view of the finding that obesity and psoriasis often go hand in hand. Amevive’s long remission periods make it a good choice for those who need to travel. For example, if you’re planning an around-the-world trip or a safari to Africa, you certainly don’t want to carry drugs with you that require refrigeration. Unfortunately, Amevive is not as uniformly effective for patients, some do great on this drug; however many do not get significant benefit. The average time to maximum improvement is around 14 weeks.

Side Effects

It is not unusual to see local injection site reactions (redness and tenderness) where the medications are injected into the body. All the biologics affect the immune system, therefore there is concern with all of them regarding serious infections and malignancy. Many dermatologists now do a PPD test for tuberculosis exposure before starting biologic drugs. Hepatitis B exposure can be tested for as well. As a rule, these drugs are not a good choice for patients who have a history of cancer and of course are contraindicated in patients actively being treated for cancer. Having psoriasis itself actually increases the risk of some types of lymphoma, taking biologic drugs may or may not increase this risk. As a class, the TNF-alpha blocking drugs share several side effects and warnings beyond serious infections and malignancy:

• Patients with a history of any sort of demyelinating disorder such as multiple sclerosis should not use TNF-alpha blocking drugs
• Those with congestive heart failure should not use these drugs.
• TNF-alpha blocking drugs have been linked to blood problems like pancytopenia (decrease in production of all blood cell types) and aplastic anemia (complete loss of production of red blood cells). Routine blood tests should be done while taking these drugs and any problems such as fever, bleeding, bruising, and pallor (unusual paleness) should be reported immediately.
• No live vaccines should be taken while on TNF-alpha blockers (ask your doctor about any vaccines you may be considering).
• Autoimmune and lupus-like problems have been reported with these drugs.

Amevive is contraindicated (should never be used) in patients with HIV infection. It may cause lymphopenia (low white blood cells) which can lead to serious infection. Like other biologics, it should not be used in patients with a history of, or active cancer. Liver injury has been reported with the use of Amevive, but often in conjunction with other liver-damaging drugs or alcohol. Raptiva has been associated with serious infection like all biologics. It should not be used in patients with current cancer or history of cancer. More studies for Raptiva are proving less worrisome in regard to infection and malignancy than earlier believed. About 0.7% of patients starting Raptiva have a worsening of their psoriasis. About one in a 1,000 patients will get low platelets (blood clotting cells). Because of this, platelet counts are checked quarterly while on Raptiva. Vaccines of all types may not work as well while patients are on Raptiva.

For further details, consult your physician.

_Source:

Amevive prescribing information, Enbrel prescribing information, Humira prescribing information, Raptiva prescribing information.