Psoriasis: Adalimumab recommendations

  • Indications: moderate to severe psoriatic arthritis, moderate to severe psoriasis, adult and juvenile rheumatoid arthritis (as young as age 4 y), ankylosing spondylitis, and Crohn’s disease
  • Dosing for psoriasis: 80 mg the first wk, 40 mg the second wk, followed by 40 mg every other wk given subcutaneously dShort-term results: 80% of patients achieve PASI-75 at 12 wk
  • Long-term results: 68% of patients achieve PASI-75 at 60 wk
  • Small percentage of patients lose efficacy with continued use
  • Toxicities:
    • Moderately painful injection site reactions are noted
    • Rare reports of serious infections (i.e., tuberculosis and opportunistic infections)and malignancies
    • There are rare reports of drug-induced, reversible side effects including lupus without renal or CNS complications, cytopenia,MS, and exacerbation of and new onset of CHF
  • Baseline monitoring:
    • PPD is required
    • LFT, CBC, and hepatitis profile
  • Ongoing monitoring:
    • Periodic history and physical examination are recommended while on treatment
  • Consider a yearly PPD, and periodic CBC and LFT
  • Pregnancy category B

Level of Evidence I Strength of Recommendation A


Read more on adalimumab

 

Efficacy

Adalimumab is the first fully human anti-TNF-α-monoclonal antibody. It binds specifically to soluble and membrane-bound TNF-α and blocks TNF-α interactions with the p55 and p75 cell surface TNF receptors.46 Adalimumab is currently approved for psoriasis, juvenile rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, adult rheumatoid arthritis, and Crohn’s disease. Adalimumab dosing for psoriasis is 80 mg given subcutaneously the first week, followed by 40 mg subcutaneously given the next week and then every 2 weeks thereafter.121,122 In the phase III studies of adalimumab, 1212 patients were randomized to receive adalimumab (given as 80 mg at week 1, 40 mg at week 2,and then 40 mg every other week) or placebo for the first 15 weeks. At week 16, 71% of patients treated with adalimumab and 7% treated with placebo achieved at least PASI-75. During weeks 33 to 52, the percentage of patients rerandomized to placebo who lost adequate response (defined as 50% improvement in the PASI score and at least a 6-point increase in PASI score from week 33) was 28% compared with 5% of patients treated continuously with adalimumab.47 Adalimumab is used continuously, at a dosage of 40 mg every other week. Rebound does not typically occur when adalimumab is discontinued, however, clearance is better maintained with continuous use and there is loss of efficacy after restart of adalimumab.47

Safety

Adalimumab is the newest of the TNF inhibitors, and available safety data are more limited than for etanercept or infliximab. Adalimumab injections can lead to painful injection site reactions in up to 15% of patients. These reactions usually resolve spontaneously within the first 2 months of therapy.

References

46. Gordon KB, Langley RG, Leonardi C, Toth D, Menter MA, Kang S, et al. 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 Dermatol 2006;55:598-606.
47. Menter A, Tyring SK, Gordon K, Kimball AB, Leonardi CL, Langley RG, et al. Adalimumab therapy for moderate to severe psoriasis: a randomized, controlled phase III trial. J Am Acad Dermatol 2007;58:106-15.
121. Patel T, Gordon KB. Adalimumab: efficacy and safety in psoriasis and rheumatoid arthritis. Dermatol Ther 2004;17: 427-31.
122. Gordon K. Efficacy and safety of adalimumab treatment in patients with moderate to severe psoriasis: a double-blind, randomized clinical trial. Psoriasis Forum 2007;13:4-11.

Navigate section 1 of the psoriasis guideline: Biologics

Citation note

When referencing this guideline in a publication, please use the following citation: Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB,et al. 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 Dermatol. 2008 May;58(5):826-50. 



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