At-Home UVB Therapy vs. Systemic Therapies
Calculating the Lifetime Cost of Care Compared to Other Therapies
At-home treatments with ultraviolet type-B (UVB) phototherapy can offer a convenient, cost-effective and efficacious choice for treatment of your patients’ psoriasis, researchers noted in a poster they presented at this year’s American Academy of Dermatology.
Published studies indicate that efficacy of UVB phototherapy is anywhere from 60% effective for broad-band UVB to nearly 80% effective for narrow-band UVB for treating psoriasis.
To compare treatment options, researchers developed a payer-perspective model that they used to calculate the cost of home UVB phototherapy, topical psoralen-UVA (PUVA), and other systemic treatments for psoriasis such as acitretin, methotrexate, efalizumab (Raptiva) etanercept (Enbrel), adalimumab (Humira) and alefacept (Amevive). For more specifics on the therapies studied, see Table One: “Treatments at a Glance.”

Only direct costs (not the time commitment associated with some therapies) of treatment and follow-up were included in this study, and the treatment period selected was 30 years to represent the chronic nature of psoriasis. So, for example, for home phototherapy these costs included the price of the unit, bulb replacement every 5 years and follow-up visits every 3 months. For PUVA and other systemic therapies, the costs associated with treatment included the cost of the drug, drug administration costs (if applicable), laboratory monitoring and follow-up visits.
After gathering and analyzing the data, researchers concluded that phototherapy continues to be “an effective and relatively inexpensive option for many patients.” They further stated that “Insurers should reduce disincentives to phototherapy treatment,” and that they should encourage physicians to “make greater use of home phototherapy treatment options.”
Here were some specific findings:
• Home UVB monotherapy cost about $7,100 for a 30-year course of treatment.
• The cost of methotrexate was $19,100.
• PUVA therapy came in around $37,600.
• Acitretin monotherapy cost about $75,100.
• Treatment with biologic therapies ranged from $171,900 to $319,356.
For more details on cost comparisons, see Table Two: “How the Treatments Compare.”

Authors: CB Yelverton, AS Kulkarni, R Balkrishnan, SR Feldman.

Free Treatment Guide
Looking for a tool to better help you develop a treatment strategy for your psoriasis patients? The National Psoriasis Foundation is of-fering the second edition of The Psoriasis and Psoriatic Arthritis Pocket Guide for free.
Developed by an expert panel of clinicians, the guide is designed to do the following:
• Define the severity of psoriasis and psoriatic arthritis and develop an appropriate treatment plan.
• Differentiate psoriasis from other diseases with similar looking lesions.
• Diagnose patients who have moderate or severe disease and determine which patients would best benefit from systemic therapy.
• Discuss therapeutic options and appropriate doses that correspond to a patient’s disease stage.
Authors of the book include Dr. Steven Feldman, Dr. John Koo, Dr. Mark Lebwohl, Dr. Alan Menter and Dr. Abby Van Voorhees.

To order your free guide, contact the National Psoriasis Foundation at physicians@psoriasis.org, or call (800) 723-9166.

3-Year Study Results for Efalizumab
At this year’s winter American Academy of Dermatology meeting, final results were presented from a 3-year study with efalizumab (Raptiva).
“This is the longest continuing dose trial with a biologic for the treatment of psoriasis,” explained Dr. Craig Leonardi, who is an Associate Clinical Professor of Dermatology at St. Louis University Medical School and has had extensive experience with the biologics.
In addition, Dr. Leonardi said that this study represents the first time that a biologic therapy for psoriasis has shown a “sustained benefit” for psoriasis patients who have been treated with it continuously for 3 years.
Data from the 36-month, Phase IIIb open-label study of patients with moderate-to-severe plaque psoriasis indicated the following findings.
At 33 months, 151 patients remained in the study and continued to receive weekly therapy with efalizumab. Results showed that:
• 75% of these patients had a 75% or greater improvement on the Psoriasis Area Severity Index (PASI-75).
• 41% of patients achieved PASI-90.
At 36 months, 113 patients remained in the study and were still receiving weekly therapy. Results from these patient results include the following:
• 73% of patients achieved PASI-75.
• 40% of patients achieved PASI-90.
In addition to studying patients taking efalizumab alone, a small number of patients underwent concomitant therapy such as corticosteroids or UVB phototherapy, for examples. However, none of these additional therapies had a significant effect on patient response rates.

Study Authors: CL Leonardi, KB Gordon, TK Hamilton, I Caro, P Kwon, R Chastain, AB Gottlieb.

Anti-Interleukin-12 and Interleukin-23 Show Promise
At the Society for Investigational Dermatology meeting this past May in St. Louis, researchers reported that an experimental drug, CNTO 1275, appeared “highly effective and well tolerated in the short-term treatment of psoriasis.” This therapy, which is in Phase II trials under the aegis of Centocor, is a human monoclonal antibody against the p40 subunit of interleukin-12 (IL-12) and interleukin-23 (IL-23).
A double-blind, placebo-controlled Phase II study of 321 patients with moderate to severe psoriasis were randomized to receive either placebo or a subcutaneous dose of CNTO 1275 in one of the following amounts: a 50-mg single dose, a 100-mg single dose, 50-mg weekly for 4 weeks (200 mg total), 100-mg weekly for 4 weeks (400 mg total).
Patients were assessed at 12 weeks for achievement of PASI-75, and the results are as follows:
• 50-mg dose: 51.6% of patients undergoing treatment vs. 1.6% receiving placebo
• 100-mg dose: 59.4% of patients undergoing treatment vs. 23.4% receiving placebo
• 200-mg dose: 67.2% of patients undergoing treatment vs. 29.7% receiving placebo
• 400-mg dose: 81.3% of patients undergoing treatment vs. 43.8% receiving placebo.
PASI-90 was achieved in 51.6% of patients in the entire treatment group vs. 1.6% in the placebo group. In addition, 79.4% of patients in the CNTO 1275 treatment group experienced at least one adverse event vs. 71.6% in the placebo group. However, most adverse events were not serious. Serious adverse events were experienced in 3.6% of the treatment group vs. 1.5% in the placebo group.

Study Authors: R Langley, M Lebwohl, C Leonardi, N Yeilding, C Guzo, Y Wang,
L Dooley, GG Kreuger.

Recalcitrant Hand and Foot Psoriasis: One Successful Patient Case
A 54-year-old mechanic with a 7-year history of hand and foot psoriasis presented with a flare-up of the disease (see photo above left). At the time this photograph was taken, the patient was undergoing combination therapy with etanercept (Enbrel), cyclosporine and acitretin. However, after 3 months of this combination therapy, the patient experienced only minimal improvement.

Past Treatment Successes and Failures
The first treatment he’d received was with acitretin and topical psoralen-UVA (PUVA), which cleared the symptoms, and he was maintained on this regimen for 18 months. When his psoriasis again flared during treatment, a subsequent increase in the dosage of acitretin and increased frequency in PUVA treatments failed to have an effect on his symptoms. Soon afterward, these treatments were discontinued, and methotrexate was added to the regimen. However, this treatment was not effective and was discontinued after 10 weeks. The patient then underwent treatment with cyclosporine and topical PUVA. This therapy was only effective at cyclosporine doses higher than 4 mg/kg, and the patient experienced adverse events (hard-to-control hypertension and malaise). Next, the patient received therapy with etanercept (Enbrel), cyclosporine and acitretin, but this therapy was only minimally successful after 3 months.

Another Try
In March 2004, the patient began therapy with efalizumab (Raptiva) at a dose of 1 mg/kg per week subcutaneously. Cyclosporine 3.5 mg/kg per day as well as acitretin 25 mg per day were continued until the patient showed a response to therapy.
By 8 weeks, the patient’s hand and foot psoriasis had dramatically improved and cyclosporine was tapered. By the twelfth week, the patient’s psoriasis was nearly clear and cyclosporine was discontinued. The patient continued receiving efalizumab weekly plus a lowered dosage acitretin (25 mg every other day). See the “after” photo for results. The acitretin could be discontinued 3 months later.
Fifteen months after this patient began therapy with efalizumab, his disease remained well controlled. The only other systemic therapy the patient needed was occasional use of Class 1 topical corticosteroids.

Case Study Author: J Crowley.

Etanercept Approved for Expanded Indication for Psoriatic Arthritis
Etanercept (Enbrel), which was granted approval to treat psoriatic arthritis in 2002, has now received approval for an expanded indication. The drug is now also indicated for the improvement of physical function in patients who have psoriatic arthritis — the first drug to obtain this expanded indication. For more details of this approval, see page 17 of this month’s “FDA Approvals & News.”