Switching between biologic drug classes in adults with psoriasis improved skin clearance in both the short and long term, without increasing overall safety risks compared with staying on the same therapy, according to a review of randomized clinical trials.
The analysis included 24 randomized trials of 12,661 adults with plaque psoriasis.Interclass switching—changing from one biologic drug class to another after loss of efficacy, treatment failure, or adverse effects—was associated with significant short-term Psoriasis Area and Severity Index (PASI) gains within 4 weeks, which were largely maintained long term. The greatest improvements followed switches from tumor necrosis factor (TNF)-α inhibitors to interleukin (IL)-23p19 inhibitors and from IL-12/23p40 inhibitors to IL-23p19 inhibitors. TNF-α to IL-17A switching yielded faster short-term responses, while IL-12/23p40 to IL-17A/F also proved effective.
Efficacy outcomes, including PASI improvement, physician-assessed clearance, and patient-reported quality of life, were similar to those who remained on the same biologic. Safety outcomes were generally comparable, though TNF-α to IL-17A switching was linked to slightly higher fungal (0.24%) and Candida (0.16%) infection rates. Patients switching from TNF-α to IL-23p19, IL-17A, or IL-12/23p40 inhibitors had the highest overall infection rates (0.62%, 0.54%, and 0.39%). Rates of nasopharyngitis (up to 0.25%) and arthralgia (0.14%) were also modestly higher with certain switches.
Lead author Miao Zhang, MD, of Shanghai University of Traditional Chinese Medicine, and colleagues wrote that interclass biologic switching challenges the traditional stepwise psoriasis treatment ladder, aligning with findings from the BIOBADADERM cohort study. They emphasized, however, that infection monitoring remains important after switching.
The proportion of patients who were on biologic therapy increased over time, they wrote, while the proportion of patients on classic therapy decreased. Patients were more likely to stay in the biologic group after switching and were more likely to switch with follow-up.
The study had several limitations. Differences in how trials defined switching time points and follow-up periods made direct comparisons difficult. Variations in drug batches and patient populations may also have influenced outcomes. In addition, insufficient data for some comparisons, small sample sizes, and wide confidence intervals reduced the certainty of findings. Because the analysis was based on clinical trials with specific eligibility criteria, the results may not fully reflect outcomes in routine clinical practice.
The authors reported no conflicts of interest.
Source: JAMA Dermatology
