Moderate-to-Severe Plaque Psoriasis: When Biologic Monotherapy Has Only Partially Responded
Clinical Scenario
This protocol addresses patients with moderate-to-severe plaque psoriasis who have been treated with biologic monotherapy but have not reached the defined response threshold. The central question is how to proceed when the initial biologic has delivered only a partial improvement.
Prior Treatment — Failure Condition
The preceding treatment line involves biologic monotherapy — agents in this category include etanercept, infliximab, adalimumab, certolizumab, ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab, tildrakizumab, and risankizumab.
Escalation to this protocol is indicated when the biologic has not achieved PASI 75 (75% improvement in the Psoriasis Area Severity Index) after 12 to 16 weeks of continuous therapy — or after 8 to 10 weeks specifically for infliximab.
Next-Step Approach (Partial Overview)
For patients with only a partial response, the approach involves either adjusting the current biologic — by modifying the dose or the dosing interval — or supplementing it with an additional treatment modality. Several categories of add-on therapy may be appropriate depending on the clinical picture. The complete set of options, their sequencing, and the criteria that apply to each are detailed in the full protocol.
Treatment Goal
PASI 75 — 75% improvement in the Psoriasis Area Severity Index.
References
- Consider dose escalation, an increase in frequency, or the addition of other modalities (such as topical corticosteroids or vitamin D analogues, methotrexate, acitretin, apremilast, or NB-UVB) in partially responding patients.
- Particularly in infliximab, consider an increase in dosing frequency before an increase in dose in terms of mg/kg.
DOI: 10.1016/j.jaad.2018.11.057
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