Psoriasis: Systemic Therapy

Question 1

Name the non-biological agents and biological agents used in psoriasis.

Answer 1

Non-Biological

• Methotrexate
• Ciclosporin

Biological

• Adalimumab
• Etanercept
• Infliximab
• Ustekinumab

Question 2

Where should these therapies only be initiated?

Answer 2

In secondary care

Question 3

What are the NICe criteria for starting non-biological systemic therapy?

Answer 3

• It cannot be controlled with topical therapy and
• It has a significant impact on physical, psychological or social wellbeing and
• One or more of the following apply:
  
  • Psoriasis is extensive (for example, >10%TBSA or a PASI score of >10)
  • Psoriasis is localised & associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites)
  • Phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months)

Question 4

Which non-biological systemic therapy is used first?

Answer 4

Methotrexate

Question 5

In what scenarios would ciclosporin be used before methotrexate (non-biological therapies)?

Answer 5

• Need rapid or short-term disease control (for example a psoriasis flare) or
• Have palmoplantar pustulosis or
• Are considering conception (both men and women) and systemic therapy cannot be avoided

Question 6

Which biological systemic therapies are given by subcut injections?

Answer 6

• Adalimumab
• Etanercept
• Ustekinumab

Infliximab is given by IV infusion.

Question 7

What is required for a patient with psoriasis to be offered biological systemic therapy?

Answer 7

A failed trial of non-biological treatment or PUVA.