The use of biologic medications for psoriasis is a recent therapeutic advance.
Objective:
To review clinical and economic data for biologic therapies in the treatment of chronic plaque psoriasis.
Methods:
Published meta-analyses and additional literature review identified randomized controlled trials. Analyses included the number needed to treat (NNT), the cost in Canadian dollars for the first year of treatment per the Canadian product monograph, and the estimated cost per responder achieving a 75% reduction in Psoriasis Area and Severity Index score (PASI 75).
Results:
Pooled NNTs were 1.3 (infliximab), 1.5 (ustekinumab 90 mg), 1.6 (adalimumab and ustekinumab 45 mg), 2.3 (etanercept), 4.1 (efalizumab), and 5.6 (alefacept). The annual treatment cost per patient was $19,825 to $37,600. The cost per patient achieving a PASI 75 response at 12 weeks ranged from $8,330 (adalimumab) to $71,371 (alefacept).
Conclusion:
This analysis suggests favorable cost and benefits of biologic psoriasis therapies, particularly adalimumab, infliximab, and ustekinumab.
Get full access to this article
View all access options for this article.
References
1.
LangleyRGKruegerGGGriffithsCE. Psoriasis: Epidemiology, clinical features, and quality of life. Ann Rheum Dis2005;64Suppl 2:ii18-–23.
2.
GuentherLLangleyRGShearNH. Integrating biologic agents into management of moderate-to-severe psoriasis: A consensus of the Canadian Psoriasis Expert Panel. February 27, 2004. J Cutan Med Surg2004;8:321–37.
3.
LangleyRGGuptaAKChermanAM. Biologic therapeutics in the treatment of psoriasis. Part 1: Review. J Cutan Med Surg2007;11:99–122.
4.
LangleyRGGuptaAKChermanAM. Biologic therapeutics in the treatment of psoriasis. Part 2: Practical considerations. J Cutan Med Surg2007;11:145–9.
GordonKBLangleyRGLeonardiC. Clinical response to adalimumab treatment in patients with moderate to severe psoriasis: Double-blind, randomized controlled trial and open-label extension study. J Am Acad Dermatol2006;55:598–606.
12.
MenterATyringSKGordonK. Adalimumab therapy for moderate to severe psoriasis: A randomized, controlled phase III trial. J Am Acad Dermatol2008;58:106–15.
13.
SauratJHStinglGDubertretL; CHAMPION Study Investigators. Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION). Br J Dermatol2008;158:558–66.
14.
KruegerGGPappKAStoughDB. A randomized, double-blind, placebo-controlled phase III study evaluating efficacy and tolerability of 2 courses of alefacept in patients with chronic plaque psoriasis. J Am Acad Dermatol2002;47:821–33.
15.
EllisCNMordinMMAdlerEY. Effects of alefacept on health-related quality of life in patients with psoriasis: Results from a randomized, placebo-controlled phase II trial. Am J Clin Dermatol2003;4:131–9.
16.
LebwohlMChristophersELangleyR; Alefacept Clinical Study Group. An international, randomized, double-blind, placebo-controlled phase 3 trial of intramuscular alefacept in patients with chronic plaque psoriasis. Arch Dermatol2003;139:719–27.
17.
OrtonneJP. Clinical response to alefacept: Results of a phase 3 study of intramuscular administration of alefacept in patients with chronic plaque psoriasis. J Eur Acad Dermatol Venereol2003;17Suppl 2:12-–6.
18.
GordonKBPappKAHamiltonTK; Efalizumab Study Group. Efalizumab for patients with moderate to severe plaque psoriasis: A randomized controlled trial. JAMA2003;290:3073–80.
19.
LebwohlMTyringSKHamiltonTK; Efalizumab Study Group. A novel targeted T-cell modulator, efalizumab, for plaque psoriasis. N Engl J Med2003;349:2004–13.
20.
LeonardiCLPappKAGordonKB; Efalizumab Study Group. Extended efalizumab therapy improves chronic plaque psoriasis: Results from a randomized phase III trial. J Am Acad Dermatol2005;52:425–33.
21.
PappKABressinckRFretzinS; Efalizumab Study Group. Safety of efalizumab in adults with chronic moderate to severe plaque psoriasis: A phase IIIb, randomized, controlled trial. Int J Dermatol2006;45:605–14.
22.
DubertretLSterryWBosJD; CLEAR Multinational Study Group. Clinical experience acquired with the efalizumab (Raptiva) (CLEAR) trial in patients with moderate-to-severe plaque psoriasis: Results from a phase III international randomized, placebo-controlled trial. Br J Dermatol2006;155:170–81.
23.
LeonardiCLPowersJLMathesonRT; Etanercept Psoriasis Study Group. Etanercept as monotherapy in patients with psoriasis. N Engl J Med2003;349:2014–22.
24.
PappKATyringSLahfaM; Etanercept Psoriasis Study Group. A global phase III randomized controlled trial of etanercept in psoriasis: Safety, efficacy, and effect of dose reduction. Br J Dermatol2005;152:1304–12.
25.
TyringSGottliebAPappK. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: Double-blind placebo-controlled randomised phase III trial. Lancet2006;367:29–35.
26.
ChaudhariURomanoPMulcahyLD. Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: A randomised trial. Lancet2001;357:1842–7.
27.
GottliebABEvansRLiS. Infliximab induction therapy for patients with severe plaque-type psoriasis: A randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol2004;51:534–42.
28.
ReichKNestleFOPappK; EXPRESS Study Investigators. Infliximab induction and maintenance therapy for moderate-to-severe psoriasis: A phase III, multicentre, double-blind trial. Lancet2005;366:1367–74.
29.
MenterAFeldmanSRWeinsteinGD. A randomized comparison of continuous vs. intermittent infliximab maintenance regimens over 1 year in the treatment of moderate-to-severe plaque psoriasis. J Am Acad Dermatol2007;56:31.e1–15.
30.
LeonardiCLKimballABPappKA. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet2008;371:1665–74.
31.
PappKALangleyRGLebwohlM. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet.2008;371:1675–84.
32.
IrvineEJ. Measurement and expression of risk: Optimizing decision strategies. Am J Med2004;117Suppl 5A:2S-–7S.
33.
DawesMSummerskillWGlasziouP; Second International Conference of Evidence-Based Health Care Teachers and Developers. Sicily statement on evidence-based practice. BMC Med Educ2005;5:1.
34.
ManriquezJJVilloutaMFWilliamsHC. Evidence-based dermatology: Number needed to treat and its relation to other risk measures. J Am Acad Dermatol2007;56:664–71.
35.
BrimhallAKKingLNLicciardoneJC. Safety and efficacy of alefacept, efalizumab, etanercept and infliximab in treating moderate to severe plaque psoriasis: A meta-analysis of randomized controlled trials. Br J Dermatol2008;159:274–85.
36.
SirtoriCRCalabresiLMarchioliR. Cardiovascular risk changes after lipid lowering medications: Are they predictable?Atherosclerosis2000;152:1–8.
37.
SchoenfeldPScheimanJ. An evidence-based approach to studies of gastrointestinal therapies. Clin Gastroenterol Hepatol2003;1:57–63.
38.
TramèrMRWalderB. Number needed to treat (or harm). World J Surg2005;29:576–81.
39.
FrancisGS. Importance of benefit-to-risk assessment for disease-modifying drugs used to treat MS. J Neurol2004;251Suppl 5:v42-–9.
40.
FinnerupNBOttoMMcQuayHJ. Algorithm for neuropathic pain treatment: An evidence based proposal. Pain2005;118:289–305.
41.
BoudreauRBlackhouseGGoereeR. Adalimumab, alefacept, efalizumab, etanercept, and infliximab for severe psoriasis vulgaris in adults: budget impact analysis and review of comparative clinical- and cost-effectiveness. Technology report number 97. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2007.
42.
WoolacottNHawkinsNMasonA. Etanercept and efalizumab for the treatment of psoriasis: A systematic review. Health Technol Assess2006;10:1–233, i–iv.
43.
BansbackNSiztoSSunH. Efficacy of systemic treatments for moderate to severe plaque psoriasis: Systematic review and meta-analysis. Dermatology2009. DOI 10.1159/000233234.
44.
DerSimonianRLairdN. Meta-analysis in clinical trials. Control Clin Trials1986;7:177–88.
45.
DalyLE. Confidence limits made easy: Interval estimation using a substitution method. Am J Epidemiol1998;147:783–90.
46.
HalvorsenPASelmerRKristiansenIS. Different ways to describe the benefits of risk-reducing treatments: A randomized trial. Ann Intern Med2007;146:848–56.
47.
ChongCATomlinsonGChodirkerL. An unadjusted NNT was a moderately good predictor of health benefit. J Clin Epidemiol2006;59:224–33.
48.
McAlisterFA. The “number needed to treat” turns 20—and continues to be used and misused. CMAJ2008;179:549–53.
49.
YuAPJohnsonSWangST. Cost utility of adalimumab versus infliximab maintenance therapies in the United States for moderately to severely active Crohn's disease. Pharmacoeconomics.2009;27:609–21
50.
GriffithsCStroberBvan der KerkhofP. A phase 3, multicenter, randomized study comparing ustekinumab and etanercept for the treatment of moderate to severe plaque psoriasis. Presented at the 17th Congress of the European Academy of Dermatology and Venereology; 2008 Sep 17–21; Paris, France.
51.
CimminoMA. Epidemiology of psoriasis and psoriatic arthritis. Rheumatismo2007;59Suppl 1:19-–24.
52.
MenterAGottliebAFeldmanSR. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol2008;58:826–50.
53.
GottliebAKormanNJGordonKB. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol2008;58:851–64.
54.
HuangWCordoroKMTaylorSL. To test or not to test? An evidence-based assessment of the value of screening and monitoring tests when using systemic biologic agents to treat psoriasis. J Am Acad Dermatol2008;58:970–7.
55.
National Institute for Health and Clinical Excellence. Etanercept and efalizumab for the treatment of adults with psoriasis. NICE technology appraisal guidance no. 103. Available at: http://www.nice.org.uk/TA103 (accessed January 29, 2009).
56.
SiztoSBansbackNFeldmanSR. Economic evaluation of systematic therapies for moderate to severe psoriasis. Br J Dermatol2009;160:1264–72.
57.
NelsonAAPearceDJFleischerAB. New treatments for psoriasis: Which biologic is best?J Dermatolog Treat2006;17:96–107.
58.
NelsonAAPearceDJFleischerABJr. Cost-effectiveness of biologic treatments for psoriasis based on subjective and objective efficacy measures assessed over a 12-week treatment period. J Am Acad Dermatol2008;58:125–35.
