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Treating Psoriasis If Enbrel Fails

Study Shows Stelara and Remicade Are Both Effective if Enbrel Stops Working

By Charlene Laino
WebMD Health News
Reviewed by Louise Chang, MD

March 8, 2010 (Miami Beach, Fla.) -- If the drug Enbrel stops working, people with psoriasis have two effective options, new research suggests.

One new study shows that the recently approved drug Stelara can help treat moderate to severe psoriasis if Enbrel fails.

A second study suggests Remicade is effective for people with psoriasis who are no longer helped by Enbrel.

The findings were presented at the annual meeting of the American Academy of Dermatology. Both studies were sponsored by Centocor, which makes Stelara and Remicade.

About 7.5 million Americans suffer from psoriasis, a lifelong disorder characterized by inflammation of skin and, often, the joints.

Stelara, Remicade, and Enbrel are all biologics -- drugs made of genetically engineered proteins -- that are generally used to treat patients who aren't responding to traditional therapies such as light therapy and methotrexate.

Remicade and Enbrel both block tumor necrosis factor-alpha (TNF-alpha), a chemical produced by immune cells that fuels inflammation, much like gas on a fire. Stelara targets two proteins, interleukin 12 and interleukin 23, that also drive the inflammatory process.

The new findings show that if Enbrel stops working, "there are other effective options," says Alan Menter, MD, chair of the psoriasis research unit at Baylor Research Institute in Dallas.

Menter was an investigator in the Stelara study, a follow-up analysis of a larger trial of more than 900 patients that showed Stelara was more effective than Enbrel in the treatment of moderate-to-severe plaque psoriasis.

Comparing Psoriasis Treatments

The new analysis focused on 50 patients who continued to have moderate-to-severe psoriasis after 12 weeks of Enbrel therapy. Compared with people who were helped by Enbrel, they tended to be heavier, male, and have more severe psoriasis.

All were given Stelara injections four weeks and eight weeks later.

Three months later, 40% had, at most, minimal signs of their psoriasis; 70% had mild disease at most.

The second study involved 217 psoriasis patients who had significant disease despite ongoing treatment with Enbrel. All were switched to Remicade therapy.

"While both drugs block TNF-alpha, they do so in slightly different ways. There are subtle difference that made us think that Remicade may work more effectively," says Robert Kalb, MD, a clinical professor of dermatology at the State University of New York, Buffalo, who was involved in the trial.

By 10 weeks later, two-thirds had, at most, minimal disease.

So if you fail Enbrel, how do you decide whether to try Remicade or Stelara?

There has been no head-to head comparison, but generally Stelara is reserved for people with more severe disease, Menter notes.

"Once on it, the vast majority of patients maintain improvement over the course of the next few years," he adds.

If the patient's joints are inflamed, "I may be more likely to use a TNF-alpha blocker," which have been used to treat arthritis for over a decade, Menter says. (A study looking at the effects of Stelara on joint inflammation is just starting.)

In general, the safety of all three drugs has been similar in various studies, he says.

But Stelara has not been around long enough for researchers to know if it will increase the risk for infections or cancer, known risks of biologic agents that affect the body's immune system, says past American Academy of Dermatology president Darrell S. Rigel, MD, clinical professor of dermatology at New York University Medical Center.

The bottom line, he tells WebMD, is that many psoriasis patients have been helped by Enbrel for psoriasis.

"If it doesn't work well or stops working, [Stelara and Remicade] are very good drugs to consider. But if a drug is working, I would stay on it," he says.

SOURCES:
68th Annual Meeting of the American Academy of Dermatology, Miami Beach, Fla., March 5-9, 2010.
Alan Menter, MD, chair of the psoriasis research unit, Baylor Research Institute, Dallas.
Robert Kalb, MD, clinical professor of dermatology, State University of New York, Buffalo.
Darrell S. Rigel, MD, past president, American Academy of Dermatology; clinical professor of dermatology, New York University Medical Center.
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