NICE has recently published guidance on the use of adalimumab▼ for treating adults with psoriasis. Generally, it recommends using adalimumab only in patients who have severe plaque psoriasis, where standard systemic psoriasis treatments have been tried or are unsuitable. More specifically, the guidance recommends using adalimumab as follows:
- Adalimumab is recommended as a treatment option for adults with plaque psoriasis for whom anti-tumour necrosis factor (TNF) treatment is being considered and when the following criteria are both met.
- The psoriasis is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10
- The psoriasis has not responded to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); or the person is intolerant of, or has a contraindication to, these treatments.
- Adalimumab should be discontinued in people whose psoriasis has not responded adequately at 16 weeks.
The guidance also stresses the importance of ensuring that the severity of plaque psoriasis is assessed accurately, when using the DLQI. It is particularly important that a person’s disabilities (such as physical impairments) and linguistic and other communication difficulties are taken into account because, in these circumstances, the DLQI may not be sufficiently accurate.
Adalimumab is a monoclonal antibody that blocks the interaction of TNF factor alpha (TNF- α) with its cell surface receptors, limiting the promotion of inflammatory pathways. Other biologic agents licensed for the treatment of psoriasis include etanercept▼, efalizumab▼ and infliximab▼.
NICE has also recommended etanercept for patients with severe plaque psoriasis (PASI>10 and DLQI>10), where standard systemic psoriasis treatments have been tried or are unsuitable. Efalizumab is an option only for such patients who fail to respond to etanercept or for whom etanercept is unsuitable. Infliximab is only recommended for use in very severe psoriasis (PASI>20 and DLQI>18). The Appraisal Committee did not identify any head-to-head randomised controlled trials (RCTs) comparing adalimumab with these drugs. Therefore, due to limitations of the clinical effectiveness data and the uncertainty around cost-effectiveness, it concluded that it could not recommend adalimumab in preference to etanercept and that clinicians would need to exercise their clinical judgement in choosing between the two treatments.