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Investigational Therapies for Psoriasis


Key points

  • Investigational therapies aim to inhibit the specific immunologic mechanisms behind plaque psoriasis without widely affecting the normal immune system.

  • Pathways targeted by investigational therapies include Janus kinase, tumor necrosis factor-α, interleukin-17, and interleukin-23.

  • Phase II and phase III clinical trials have demonstrated strong safety and efficacy data for several agents, indicating an important future role in treating moderate-to-severe psoriasis.

Introduction

Enhanced insight into the immunogenetic mechanisms behind plaque psoriasis has led to the development of multiple new systemic therapies. These treatments include drugs targeting Janus kinase (JAK), tumor necrosis factor-α (TNF-α), interleukin (IL)-17, and IL-23 pathways ( Table 16.1 ). Clinical trials are currently underway to examine the safety and efficacy of these agents in moderate-to-severe patients. The treatments discussed have demonstrated promising results in phase II or phase III trials and may play an important role in future treatment algorithms.

Table 16.1
Summary of clinical trials
Data from Refs.
Primary Agent Target Source Dosing Comparisons Study Length (wk)
Tofacitinib JAK1/JAK3 Papp et al, 2012 Tofacitinib, 2–15 mg twice daily Placebo 12
Bachelez et al, 2015 Tofacitinib, 5–10 mg twice daily Etanercept, 50 mg twice weekly or placebo 12
Certolizumab TNF-α Reich et al, 2012 CZP, 400 mg at week 0, then 200–400 mg q 2 wk Placebo 12
Mease et al, 2014 CZP, 200 mg q 2 wk or 400 mg q 4 wk Placebo 24
Brodalumab IL-17R Nakagawa et al, 2016 Brodalumab, 70–210 mg Q2W Placebo 12
Papp et al, 2014 Brodalumab, 140–210 mg Q2W None 120
Mease et al, 2014 Brodalumab, 140–280 mg Q2W Placebo 12, then 40 wk open label extension with 280 mg q 2 wk
Lebwohl et al, 2015 Brodalumab, 140–210 mg Q2W Ustekinumab 45–90 mg (standard weight-based dosing) or placebo 12, then extension with brodalumab 210 mg q 2 wk or 140 mg q 2 wk, q 4 wk, or q 8 wk, or ustekinumab (standard dosing)
Guselkumab IL-23p19 Sofen et al, 2014 Guselkumab, single dose of 10–300 mg Placebo 24
Gordon et al, 2015 Guselkumab, 5 mg at weeks 0 and 4 and then q 12 wk, 15 mg q 8 wk, 50 mg at weeks 0 and 4 and then q 12 wk, 100 mg q 8 wk, or 200 mg at weeks 0 and 4 and then q 12 wk Adalimumab (standard dosing) or placebo 16, then extension through week 40 (placebo patients transitioned to guselkumab 200 mg Q8W)
Tildrakizumab IL-23p19 Papp et al, 2015 Tildrakizumab 5–200 mg at weeks 0 and 4 and then q 12 wk Placebo 52, then 20 wk follow-up
Risankizumab IL-23p19 Krueger et al, 2015 Risankizumab single dose of 0.01, 0.05, 0.25, 1, 3, or 5 mg/kg intravenously, 0.25 or 1 mg/kg subcutaneously Placebo 12

Tofacitinib

Tofacitinib is an oral JAK1/JAK3 inhibitor currently approved for rheumatoid arthritis at a dose of 5 mg twice daily. The current label includes a black box warning for serious infection and malignancy. It is under investigation for chronic plaque psoriasis. In a phase IIb, randomized, placebo-controlled trial, treatment outcomes were examined by Papp and colleagues using twice a day doses of 2 mg, 5 mg, or 15 mg. At week 12, the proportion of patients who experienced 75% or greater reduction in the Psoriasis Area and Severity Index (PASI-75) was compared with the placebo group. PASI-75 responses were achieved in 25.0% of patients receiving the 2-mg dose, 40.8% of those receiving the 4-mg dose, and 66.7% of those receiving the 15-mg dose, compared with 2.0% in patients with placebo ( P <.001 for each comparison to placebo). Infections were the most common adverse events, seen in 22.4% of the 2-mg dosing group, 20.4% of the 5-mg dosing group, 38.7% in the 15-mg dosing group, and 32% in the placebo group. Of note, 15-mg dosing was associated with statistically significant decreases in hemoglobin (−0.52 g/dL vs −0.14 g/dL with placebo; P <.05), hematocrit, and red blood cell counts as well as transient decreases in neutrophil count.

Rapid and significant improvements in itch severity have been demonstrated with tofacitinib. In patient-reported surveys using 5-mg and 10-mg twice a day dosing, reductions in the itch severity index (ISI) were evident as early as 2 or 3 days after treatment initiation. Among patients with a baseline ISI 1 or greater (indicating the presence of itch), treatment with tofacitinib provided a statistically significant reduction in pruritus ( P <.05) by day 6 and through all 12 weeks of treatment.

A phase III, noninferiority trial between tofacitinib and high-dose etanercept was conducted by Bachelez and colleagues. After 12 weeks, PASI-75 responses were achieved in 39.5% (130/329) of patients receiving 5 mg of tofacitinib twice a day and 63.6% (210/330) of patients receiving tofacitinib 10 mg twice a day, compared with 58.8% (197/335) of those receiving etanercept 50 mg twice weekly, and 5.6% (6/107) of those receiving placebo. Thus, relative to etanercept 50 mg twice weekly, noninferiority was demonstrated with 10-mg dosing of tofacitinib, but not with 5-mg dosing. The rate of adverse events was similar across all groups.

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