Psoriasis: Infliximab recommendations

  • Indications: severe psoriasis, moderate to severe psoriatic arthritis, adult rheumatoid arthritis, ankylosing spondylitis, ulcerative colitis, and Crohn’s disease
  • Dosing: 5 mg/kg dose infusion schedule at wk 0,2, and 6 and then every 6-8 wk; dose and interval of infusions maybe adjusted as needed
  • Short-term response: 80% of patients achieved a PASI-75 at wk 10, 50% PASI improvement noted by wk 2
  • Long-term response: 61% of patients achieved a PASI-75 at wk 50
  • Toxicities:
    • Infusion reactions and serum sickness can occur more commonly in patients who have developed antibodies
    • The incidence of infusion reactions may be reduced by concurrent administration o fmethotrexate
    • Rare cases of serious infections (ie, tuberculosis) and malignancies including hepatosplenic T-cell lymphoma (in children); 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:
  • Contraindications: infliximab at doses >5mg/kg should not be given to patients with New York Heart Association functional class III or IV CHF

Level of Evidence: I Strength of Recommendation: A


Read more on Infliximab

 

Efficacy

Infliximab is a chimeric antibody constructed from murine and human DNA sequences comprising a mouse variable region and human IgG1-a􏰀 constant region. Infliximab binds to both the soluble and the transmembrane TNF-a molecules, thereby neutralizing the effects of TNF-α.130 

Infliximab is approved for the treatment of psoriasis and psoriatic arthritis, adult rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease in adults and children, and ulcerative colitis. Infliximab is administered intravenously at a dose of 5 mg/kg over 2 to 3 hours at weeks 0, 2, and 6and then every 8 weeks for psoriasis and psoriatic arthritis.90 Patients are less likely to develop antibodies against infliximab (or human antichimeric antibodies) if they are continuously treated with infliximab rather than on an as-needed basis and clinical responses are better maintained with continuous compared with intermittent therapy.45,131-135 Approximately 80% of patients achieve PASI-75 at week 10 (after 3 doses of infliximab). Infliximab is remarkable for the rapidity of clinical response. Loss of efficacy over time may also occur with infliximab therapy. Some dermatologists prescribe low-dose methotrexate concurrently with the goal of decreasing the formation of antibodies against infliximab and, hence, maintaining clinical efficacy over time.45 In the pivotal phase III trial of infliximab, although 80% of patients achieved PASI-75 at week 10, by week 50, 61% of patients treated with infliximab (5 mg/kg at 8-week intervals) maintained PASI-75.45,136 A 91% improvement in the Dermatology Life Quality Index occurred after 10 weeks of therapy with infliximab.132

Safety

Infusion-related reactions occur in 16% of patients treated with infliximab compared with 6% of patients treated with placebo. Although the majority of the infusion reactions are mild consisting of pruritus or urticaria, some patients will have moderate reactions consisting of chest pain, hypertension, and shortness of breath and only rarely will severe reactions with hypotension and anaphylaxis occur. Infusion reaction risk tends to correlate with the development of human antichimeric antibodies and can usually be managed by slowing the rate of infusion or stopping treatment entirely. Patients who are concurrently treated with an immunosuppressive agent such as methotrexate or azathioprine or at regularly dosed intervals are likely to have a lowered incidence of infusion reactions.
Rare postmarketing cases of hepatosplenic T-cell lymphoma have been reported in adolescent and young adult patients with Crohn’s disease treated with infliximab.175 This rare type of T-cell lymphoma has a very aggressive disease course and is usually fatal. All of the patients who have developed hepatosplenic T-cell lymphomas during treatment with infliximab have occurred in adolescent and young adult patients who were also receiving concomitant treatment with azathioprine or 6-mercaptopurine.

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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