Monitoring
The
treatment goals include a targeted final outcome of PASI of ≤2, PGA clear or
almost clear, or DLQI of <2 or either BSA ≤3% or BSA improvement ≥75% from baseline at 3 months post-initiation of therapy. Target
response after starting treatment is a BSA of ≤1% at 3 months post-initiation and during the maintenance phase,
the target response is a BSA of ≤1% at each 6-month assessment interval. The treatment response
is achieved if the patient attains ≥75% improvement from the baseline PASI
score. Treatment failure is considered in patients when a PASI score of 50 is
not reached or DLQI >5.
The
assessment of treatment success for fast-acting drugs may be started after
induction therapy up until 16 weeks (24 weeks for slow-acting drugs) after
initiating treatment. The assessment during maintenance therapy is usually
every 8 to 12 weeks or in intervals following safety monitoring
recommendations.
The
recommended timing of response assessment of immunomodulators are as follows:
- Ten weeks: Infliximab
- Twelve weeks: Brodalumab, Etanercept, Ixekizumab, Secukinumab
- Sixteen weeks: Adalimumab, Bimekizumab, Certolizumab, Guselkumab, Risankizumab, Ustekinumab
- Sixteen to Twenty-four weeks: Deucravacitinib
- Twenty-eight weeks: Tildrakizumab
In patients with PASI <50 or PASI ≥50 but <75 and DLQI >5, modifying the treatment regimen is recommended which may include dose escalation, reducing dose intervals, addition of a topical agent, or another systemic agent, or switching to another drug. Strategies to increase the effectiveness of the biological agents when treatment goals are not met include increasing the dose, shortening the dosing intervals or addition of another drug (combination therapy). Notably, switching to another drug may be necessary when dose adjustments are not appropriate or are ineffective. Follow-up is recommended every 3 months for the first year, then every 6 months thereafter if with stable results. Dose escalation may be considered in patients with PASI 50 with significant disease burden, inadequate primary response due to insufficient dosing, or to maintain treatment response during maintenance therapy. Lastly, treatment should be discontinued and second-line therapy should be considered if treatment response is not achieved.
Complications
Psoriasis has been linked to multiple comorbidities due to shared immunological mechanisms. Patients are at higher risk for cardiovascular diseases such as ischemic heart disease, myocardial infarction, arrhythmia, thromboembolism, stroke and cardiovascular death. There is also higher risk for metabolic dysfunction-associated steatotic liver disease (MASLD), mental disorders (eg depression, generalized anxiety, personality disorders, schizophrenia, vascular dementia), sleep apnea, chronic kidney disease, and end-stage renal disease. Psoriasis patients are also at increased risk for malignancies (eg cutaneous T-cell lymphoma/mycosis fungoides, Hodgkin’s lymphoma, leukemia, multiple myeloma, non-Hodgkin’s lymphoma).