PracticeUpdate Conference Series World Congress of Dermatology 2019

Systemic Psoriasis Treatments Equally Effective in Older and Younger Patients Small differences in efficacy by age in the first months of therapy disappear within a year. P atients aged 65 and older can benefit from systemic treatments for psoriasis as much as younger patients can, according to a presenta- tion at WCD 2019.

The study was led by Florian Anzengruber, MD, of University Hospital Zurich and presented by coauthor Matthias Augustin, MD, of Dermatologikum Berlin and Sciderm Research Institute in Hamburg, Germany. Quite a large number of patients continue to suffer from psoriasis into their 70s, 80s and 90s, said Dr. Augustin during his presentation, which was attended by Elsevier’s PracticeUpdate . “We also know that there is a much higher rate of comorbidity in patients who are 60 to 80 and beyond age 80,” he said.

Dr. Matthias Augustin

“There is a general exclusion of elderly patients in clinical trials, starting at the age of sometimes 65 or 70 years, and this results in limited data on effectiveness and safety of psoriasis drugs for people of this age. We also know that there are differences in the profiles of adverse events among patients … with comorbidities [and who are] elderly.” In addition, he said, the use of biologic agents for psoriasis is much greater among younger patients than among older ones. To better characterize the role of systemic antipsoriatics among the elderly, the investigators prospectively collected data on 5345 patients with mod- erate-to-severe psoriasis who were included in the German (PsoBest) and Swiss (SDNTT) psoriasis registries. All patients included in the analysis had received follow-up for psoriasis for at least 10 years. The researchers stratified the cohort data into two groups, based on age: group 1 consisted of those <65 years of age (controls, n=4631) and group 2 consisted of those ≥65 years of age (elderly, n=714). They then compared the two groups with respect to response to systemic therapies using the Psoriasis Area and Severity Index (PASI) 75 or ≤3 and the Dermatology Life Quality Index (DLQI) ≤1. There were two drugs that were more frequently used in the elderly patients compared with controls: apremilast and methotrexate. All the other drugs were more commonly used in the younger patients, including all the biologics, fumaric acid esters, and ciclosporin A. The efficacy of systemic therapies, as measured by PASI, was comparable between younger and older psoriasis patients, with the exception of metho- trexate, which was more effective in older patients at early treatment (P ≤ .003 at 3 months and P ≤ .009 at 6 months). In addition, ciclosporin showed a higher response rate in younger patients after 3 months (P ≤ .001). “The differences are quite mild, but they are statistically significant due to the higher number of patients,” said Dr. Augustin. At month 12, however, no differenceswere observed for any drug studied, including all biologics studied. The reduction of DLQI also showed comparable results in elderly and younger patients. “There are very few reasons to avoid systemic drugs in elderly persons,” concluded Dr. Augustin. “It has been shown that they are effective and safe. … I think we should raise awareness and discuss possible reasons that deter dermatologists from prescribing systemic antipsoriatics in elderly patients.” He added that more data are needed on the risk of drug–drug interactions with these agents.

placebo arm and from 52.0 to 26.0 in the omali- zumab arm. The amount of reduction in AFIRMM score was not significantly different between the groups. There were also observed greater improvements in asthenia, diarrhea, gastrointesti- nal issues, allergy/flush/shock, and pruritus among those treated with omalizumab, but these did not reach statistical significance, compared with placebo. With respect to secondary endpoints, the use of omalizumab was associated with a change in AFIRMM score at the end of the study as well as a reduction in allergic reactions, visual analog scale score for major events, pressure-induced wheal and flare, and use of medications for mastocytosis. Once again, none of these changes reached sta- tistical significance, compared with placebo. The use of omalizumab but not placebo was associated with a reduction in the expression of FcεRI on mas- tocytes and basophils. There were no serious adverse events in either group, and the rate of adverse events was similar with omalizumab and placebo. There were no cases of anaphylactic shock. “We did hope that we could get better results,” con- cluded Dr. Maul. “Patients did see improvement, but it hasn’t been significant. … [The findings are] limited due to the small study sample, as it was very difficult to find patients with cutaneous mastocyto- sis who fit the [study] criteria, … [but] we did see that the symptoms of mastocytosis were improved. … What needs to be done is a multicenter, bigger trial with more than 17 patients."

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WCD 2019 • PRACTICEUPDATE CONFERENCE SERIES 19