National consensus on biologic dose reduction in psoriasis: a modified eDelphi procedure

Figures & data

Figure 1. Flow chart study design.

Table 1. Demographic characteristics of participants in the eDelphi survey.

Characteristic	n = 27
Sex (female)	19 (70.4)
Age (years), median (range)	43 (32–65)
Working experience as a dermatologist (years), median (range)	9 (0.5–30)
Experience in prescribing biologics (years), median (range)	11 (3–28)
Hospital type^a
Academic hospital	9 (33.3)
General hospital	18 (66.7)
Independent treatment center	3 (11.1)

Data are presented as n (%) unless otherwise indicated.

^aMultiple answers were possible.

Table 2. Results of the eDelphi consensus: criteria for biologic dose reduction in patients with psoriasis.

	Statement	Disagree (%)	Neither agree nor disagree (%)	Agree (%)	Mean voting score
Eligibility	Patients should have a minimum treatment duration of 6 months before DR is started^a	11.1	11.1	77.8	7.2
	Patients should preferably have a minimum duration of having low disease activity of 6 months before DR is started^b	11.1	7.4	81.5	7.4
	The decision to start with DR should be based on disease activity and the impact of psoriasis on a patients’ quality of life^a	0	11.1	88.9	7.9
	In the case of psoriatic arthritis, a rheumatologist should be consulted first before DR is started^a	0	0	100	8.6
	When starting DR, the PASI score should be ≤5 and/or the de PGA should be 0–2, together with a DLQI ≤5^a	7.4	22.2	70.4	7.0
	Outpatient clinic visits should not be performed more frequently in case of DR^a	3.7	14.8	81.5	7.8
	While awaiting more scientific evidence for dose reduction of the newer biologics (certolizumab pegol, IL-17 inhibitors, IL-23 inhibitors) no recommendations can be provided for dose reduction schedules of these biologics. However, DR can be considered in individual patients^b	3.7	25.9	70.4	7.4
(Dis)continuation	DR can be continued in case of PASI ≤5 and/or PGA 0–2, together with DLQI ≤5^a	7.4	22.2	70.4	7.4
	In case of PASI >5 and/or PGA >2 and/or DLQI >5 and/or at a patients’ request, it should be considered to return to the standard dose or the previous effective dose^a	3.7	11.1	85.2	7.7
	At patients’ request or in case it is deemed necessary by the treating physician, it is always possible to return to the standard dose or the previous effective dose^a	0	3.7	96.3	8.2
	It can be considered to further reduce the dose:^b • After at least 3 months for biologics with a short injection interval according to the standard dose (standard interval < 8 weeks). • After at least 6 months for biologics with a longer injection interval according to the standard dose (standard interval ≥ 8 weeks).	3.7	25.9	70.4	7.4
Dose reduction schedules	Dose reduction adalimumab:^a • Step 1: 40 mg every 3 weeks • Step 2: 40 mg every 4 weeks	3.7	7.4	88.9	8.0
	Dose reduction etanercept:^a • Step 1: 50 mg every 10 days • Step 2: 50 mg every 14 days	3.7	18.5	77.8	7.2
	Dose reduction ustekinumab 45 mg:^b • Step 1: 45 mg every 15 weeks (optional) • Step 2: 45 mg every 18 weeks • Step 3: 45 mg every 21 weeks (optional) • Step 4: 45 mg every 24 weeks	0	11.1	88.9	7.8
	Dose reduction ustekinumab 90 mg:^b • Step 1: 90 mg every 15 weeks (optional) • Step 2: 90 mg every 18 weeks • Step 3: 90 mg every 21 weeks (optional) • Step 4: 90 mg every 24 weeks	0	14.8	85.2	7.6

^aStatements for which consensus was reached after round 1; ^bstatements for which consensus was reached after round 2.

DR: dose reduction; PASI: Psoriasis Area and Severity Index; PGA: Physician Global Assessment; DLQI: Dermatology Life Quality Index.

Figure 2. Algorithm for biologic dose reduction (DR) in patients with psoriasis based on the consensus. DR: dose reduction; PASI: Psoriasis Area and Severity Index; PGA: Physician Global Assessment; PsA: psoriatic arthritis; DLQI: Dermatology Life Quality Index. *DR can be discontinued at any time point in case of increased psoriasis or at the patient’s request. **Continue DR: next step DR or continue lowered dose. For dosing schedules see the lowest part of the algorithm.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.