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PASI 100 response to secukinumab in primary failure to ustekinumab: analysis of cost‐effectiveness among biological drugs

PASI 100 response to secukinumab in primary failure to ustekinumab: analysis of cost-effectiveness among biological drugs Dear Editor, A 32-year-old male patient diagnosed with psoriasis since the age of 15 presented to our clinic in April 2013, with PASI = 24 and severe nail injuries. His paternal uncle also had cutaneous psoriasis. No environmental or emotional triggers of psoriasis flares/relapses were identified. Complementary exams (including CBC, lipidogram, fasting blood sugar, liver profile, kidney function, serologies for HIV 1/2, HTLV I/II, HCV and HBV, PPD, chest x-ray, and abdominal ultrasound) were all normal. The patient’s body mass index was 27.68 kg/m (80 kg of body weight and 1.70 m of height), and he was on a standard dose of statin for treating dyslipidemia. No other comorbid condition was reported. Narrowband UVB (NB-UVB) phototherapy was prescribed and because of unsatisfactory control was later changed to acitretin. The patient experienced significant worsening of skin lesions (PASI = 57.7) after 2 years on acitretin (Fig. 1a–c). Thus, ustekinumab (UST) was prescribed at 45 mg/dose, and after two doses, there was significant scaling improvement (Fig. 1d,e). However, a considerable relapse occurred after 1 month on UST. After the fourth dose (October 2017), his PASI was 35.5, though (delta of 38.4%). Given the PASI < 50 response, no-wash-out treatment was started with secukinumab (SEK) at 300 mg/dose (December 2017), leading to significant improvement of skin lesions after just 3 weeks. After nine doses of SEK, complete clearing of skin lesions (PASI 100) was achieved, along with improvement of nail lesions. Total body skin exam revealed only residual hyperpigmented macules (Fig. 1f,g). The World Health Organization (WHO) has recognized psoriasis as a chronic, severe, disabling, noncommunicable, and painful disease, without any curative treatment available so far. However, advances in effective biological therapy development contrasts with limited access to these treatments. PASI and DLQI reductions are correlated, since skin disease severity impairs patients’ quality of life. However, there are significant differences in the probability of reaching DLQI 0/1, only 40% when PASI 75 vs. 70% when PASI 90, the latter being widely considered as a treatment goal. Psoriasis treatment goals are complex to achieve, requiring not only PASI 90 and DLQI < 5 but also management of comorbid conditions. Considering the current myriad of therapeutic options, prescribers’ assessment of cost effectiveness is mandatory in order to manage finite financial resources, whether in public or private onsets. The current case reports an overweight, dyslipidemic patient with severe cutaneous psoriasis, presenting primary failure to UST but achieving PASI 100 response after switching to SEK. Although primary failure to UST could be considered surprising, considering it is one of the most effective biological agents approved for psoriasis (only 8.3% of patients do not achieve PASI 50 after 16 weeks, while 53% present PASI 90– 100 response in the same period), it is widely known that IL-17 inhibitors, such as SEK, present better effects on clearing psoriatic lesions of obese and overweight patients, as in our patient. Since our patient was on a standard dose of UST for his body weight (<100 kg), we did not consider dose escalation, in order to follow national and international dermatology/rheumatology societies’ guidelines. This report gives some insights on biologic pharmacoeconomics in the context of sparse literature of robust studies on