Pharmacotherapeutic strategies for standard treatment-resistant psoriasis

ABSTRACT

Introduction: Psoriasis management includes a variety of treatments including localized therapies and systemic treatments; however, many patients report inadequate clinical response and resistance to therapy. Currently there is no treatment algorithm that incorporates effective strategies to tackle the various barriers leading to resistance.

Areas covered: The authors evaluate the scope of resistance, the reasons it occurs, and provide the reader with strategies for overcoming resistance in both localized and systemic therapies for psoriasis.

Expert opinion: Refractory psoriasis involves modifiable and non-modifiable factors that warrant different approaches to maximize clinical response. Treatment-resistance to topical therapies may be due to poor adherence. Improving adherence involves incorporating patients’ treatment preferences, improving the physician-patient relationship, and simplifying treatment regimens. Treatment-resistance to systemic therapies can be due to non-adherence but can also be due to ineffective dosing, development of anti-drug antibodies, and severe disease that necessitates multiple drugs. After addressing non-adherence, strategies to maximize systemic therapies include increasing the dosage, combining treatments, drug switching and incorporating pharmacogenetics.

KEYWORDS:

• Adherence
• anti-drug antibodies
• dosage increase
• combination therapy
• drug switching
• treatment resistant
• pharmacogenetics

Article highlights

• 52% patients with psoriasis are dissatisfied with current treatment regimens

• Reasons for resistance include non-adherence, inadequate dosing of medications, and development of antibodies to systemic therapies

• Currently, there is limited guidance for recalcitrant psoriasis and no treatment algorithm available with effective pharmacotherapeutic strategies to overcome such resistance and improve outcomes for patients.

• Improving the relationship between the physician and patient, addressing patients’ preferences, and simplifying treatment regimens are strategies that can improve adherence

• Increasing dosage, combination therapies, drug switching, the role of pharmacogenetics should be considered in psoriasis resistant to systemic therapies if adherence has been addressed.

This box summarizes key points contained in the article.

Declaration of interest

SR Feldman has acted as a consultant, received speaker fees and/or received grant support from AbbVie, Almirall Alvotec, Advance Medical, Boehringer Ingelheim, Caremark, Celgene, Galderma Laboratories, Gerson Lehrman Group, GlaxoSmithKline/Stiefel, Guidepoint Global, Janssen Pharmaceuticals, Kikaku, Leo Pharm Inc, Eli Lilly and Company, Merck & Co., Menlo, Mylan, the National Biological Corporation, the National Psoriasis Foundation, Nova, Novartis, Pfizer Inc, Qurient Regeneron, Samsung, Sanofi, Sienna, Sun Pharma, Suncare Research, Taro, Ortho Dermatology, Valeant and Xenoport. He further declares receiving royalties from Xlibris, UptoDate and Informa and is a major owner with stock in Medical Quality Enhancement Corporation. Finally, he is the Founder, Stock Holder and Chief Technology Officer of Causa Technologies. He is also the founder and majority owner of www.DrScore.com. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.