Long-term safety of biologics in the treatment of psoriasis

Figures & data

Figure 1 Mechanism of action of biologic agents.

Notes: Red box indicates cytokine targets of currently marketed biological therapies for the management of psoriasis: ustekinumab targeting the common p40 subunit of IL12 and IL23 and etanercept, adalimumab and infliximab targeting TNFα.
Abbreviations: TIP, TNFα and inducible nitric oxide synthase producing; DC, dendritic cell; NO, nitric oxide; TNFα, tumor necrosis factor-alpha; IFN, interferon; CCL, chemokine (C-C motif) ligand 19; CXCL, chemokine (C-X-C motif) ligand; IL, interleukin; Th, T helper.

Figure 2 Prescreening for biologic agents.

Note: Screening tool used by the Department of Dermatology at Sherwood Forest Hospitals, Kingsmill Hospital, Nottinghamshire, UK.
Abbreviations: NMSC, nonmelanoma skin cancer; PASI, Psoriasis Area and Severity Index; DLQI, Dermatology Life Quality Index; UV, ultraviolet; PUVA, psoralen + UVA; HIV, Human immunodeficiency virus.

Figure 3 Summary of National Institute for Health and Clinical Excellence evidence on biologic treatments.

Abbreviations: iv, intravenous; sc, subcutaneous; TNF, tumor necrosis factor; IL, interleukin; PASI, Psoriasis Area and Severity Index; DLQI, Dermatology Life Quality Index; NICE, National Institute for Health and Clinical Excellence PUVA, psoralen + UVA; UV, ultraviolet.

Table 1 Summary of adverse events observed with the four biologic agents

	Etanercept	Adalimumab	Ustekinumab	Infliximab
Infections	Upper Respiratory Tract Infection (URTI), skin and soft tissue infection, pneumonia, opportunistic infections – tuberculosis, fungal, protozoan	URTI, skin and soft tissue infections, fungal infections, meningitis opportunistic infections – coccidioidomycosis, histoplasmosis and mycobacterium avium complex infection, tuberculosis	URTI, Nasopharyngitis, Cellulitis, Diverticulitis, Osteomyelitis, Gastroenteritis, viral infection, Urinary tract infection	Viral, Bacterial, Opportunistic infections – pneumocytosis, candiasis, listeriosis, aspergillosis and tuberculosis
Tuberculosis (TB)	Evaluate (history and examination) and screen for TB. Not for treatment if active TB or untreated latent TB
Hepatitis B virus	Can reactivate therefore test prior to initiation and get specialist advise if positive
Allergic reactions	Angioedema, urticaria	Anaphylaxis	Hypersensitivity, Severe angioedema	Anaphylaxis, Delayed hypersensitivity reaction
Malignancy	Lymphoma, Leukemia, Melanoma and NMSC	Non melanoma skin cancer (NMSC), Lymphoma	NMSC, Prostate, Colorectal, Breast, Melanoma in–situ	Lymphoma, Leukemia, Melanoma
Neurological	Central and peripheral demyelination	Central and peripheral demyelination	Dizziness, Headache, Facial palsy	Headache, vertigo dizziness, demyelinating disorders
Cardiac	Worsen cardiac failure	Worsen cardiac failure	–	Tachycardia, Cardiac Failure, Myocardial infarction
Gastrointestinal vaccinations	Autoimmune hepatitis	Abdominal pain, nausea, vomiting	Diarrhea	Diarrhea, uncommon – intestinal stenosis and perforation, pancreatitis, Liver failure
	Live viral or bacterial vaccines not to be given – ensure vaccinations up–to–date before commencing treatment
Other	Injection site reactions	Lupus like syndrome	Injection site reactions	Antinuclear antibodies, Mood changes, Interstitial lung disease