Secukinumab for Psoriasis Treatment: A Case Series

Nopriyati, Radema Maradong

Department of Dermatology and Venereology Faculty of Medicine Sriwijaya University/Dr. Moh. Hoesin General Hospital

Palembang, Indonesia

Keywords: case series, psoriasis, secukinumab, PASI, BSA.

Abstract: Psoriasis is a chronic inflammatory disease of the skin and nails, is characterized by erythematous plaques

with silvery scale or pustules lesion for psoriasis pustular. Patients can suffer for psoriasis arthritis after the

moderate to severe psoriasis occurred. Methotrexate remains a first line treatment for severe to moderate

psoriasis, but due to the limitation of this medication, we decided to use secukinumab. We reported 2

patients. First case is a patient of psoriasis vulgaris with BSA of 20% and PASI 14.1 and history of

cyclosporine A treatment for 3 months, the second case is a patient of psoriasis pustular with BSA of 22%

and PASI 6 and history of methylprednisolone treatment for 6 months. First patient treated with 150 mg of

secukinumab and the second patient treated with 300 mg of secukinumab. The result after 16 weeks

treatment was satisfied which BSA and PASI was decreased. The efficacy of secukinumab should be

considered for the treatment of moderate psoriasis.

1 INTRODUCTION

Psoriasis is a chronic immune mediated disease that

affects 2-3% of the world population and is

characterized by erythematous plaques with silvery

scale (Gudjonsson & Elder, 2012).

Various forms

such chronic plaques, is most common in 90%

patients, other variant is pustular (Gudjonsson &

Elder, 2012; Yeung & Valbuena, 2016).

Psoriasis

arthritis (PsA) occur in around 20% to 30% of

patients suffering from moderate to severe psoriasis

(Gudjonsson & Elder, 2012; Yeung & Valbuena,

2016). Pathogenesis of psoriasis related to T helper

(Th)-17 and Interleukin (IL)-17, so that the

treatment of psoriasis often requires systemic

therapy, including biologic agent (Langley et al.,

2014; Becker & Jooo, 2018). Methotrexate (MTX) is

a first line choice for moderate to severe psoriasis

(Gudjonsson & Elder, 2012). Mechanism of action

MTX is blocking dihydrofolate reductase, leading to

inhibiton of purine and pyrimidine synthesis

(Gudjonsson & Elder, 2012). Due to the limitation

of MTX we chose cyclosporine A as a second line

treatment for psoriasis. Mechanism of action

cyclosporine A is binding cyclophilin and the

resulting complex blocks calcineurin, reducing the

effect of the T cells, resulting in inhibiton of IL-2

and other cytokines (Gudjonsson & Elder, 2012).

Some patients who treated by cyclosporine A

experienced high blood pressure, then we tried

another treatment.

Secukinumab is a newly approved IL-17A

monoclonal antibody. Mechanism of action is

selectively binds to the IL-17A cytokine and inhibits

its interaction with the IL-17 receptor, and also

reduce the epidermal neutrophils levels (Fala &

Writer, 2016). The administration therapy by

injection weekly at weeks 0,1,2,3 followed by

monthly maintenance dose starting at week 4

(Beecker & Joo, 2018). The recommended dose is

300 mg but for some patients, a dose of 150 mg may

be acceptable (Fala & Writer, 2016). Common

adverse effects of secukinumab are upper respiratory

tract infections, headache, diarrhea, nausea, and

neutropenia (Roman et al., 2015).

Follow up of patients in this study based on

evaluation of psoriasis area and severity index

(PASI) (Langley et al., 2014). Here we report a

cases of psoriasis vulgaris and psoriasis pustular

treated by secukinumab.

496

Nopriyati, . and Maradong, R.

Secukinumab for Psoriasis Treatment: A Case Series.

DOI: 10.5220/0008160604960499

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 496-499

ISBN: 978-989-758-494-7

2 CASE

2.1 Case 1

A 55-years old male with erythematous plaques and

silvery scale on the scalp, face, neck, trunk and both

upper and lower extremities a year ago.

Approximately 20% of his BSA was involved, and

PASI 14.1. Laboratory examination showed elevated

of serum CRP. The patient was diagnosed with

psoriasis arthritis, he was treated with 3 months

cyclosporine but ineffective and suffered for

hypertension, then we decided to prescribed of 3

weeks 150 mg of secukinumab followed by 150 mg

every 4 weeks due to the patients’s financial. We

also prescribed omeprazole 20 mg/day and topical

treatment of cream urea 10% applied twice a day

and desoximethasone 0.25% cream twice daily. At

16 weeks, he almost reached PASI 75 (BSA of 9%,

PASI 5.9). He had not symptoms of adverse effects

(Figure 1)

2.2 Case 2

A 41-years old female with multiple 2 mm-3 mm

pustules on a diffused-erythematous and oedematous

base, some pustules developed “pus lakes” and the

rupture of pustules leave an erosions and crusts on

the trunk and both of upper and lower extremities,

since 3 years ago. Laboratory examination is normal.

Figure 1. (1a-1e) clinical features at baseline (1f-1j) clinical features at weeks 16.

Approximately 22% of her BSA was involved and

PASI 6. She was treated by unknown dose of

methylprednisolone injection followed by

methylprednisolone oral (unknown dose) for 6

months. She experienced moon face,gastritis and

striae on the abdominal due to side effects of

methylprednisolon. The patient was diagnosed with

psoriasis pustular and we decided to prescribed 3

weeks of 300 mg secukinumab followed by 300 mg

every 4 weeks. We also prescribed topical treatment

such as vaseline album twice a day followed by

vitamin C serum for hyperpigmentation lesion twice

a day. At 16 weeks, she achieved PASI 100 (both of

BSA and PASI are 0). She had not symptoms of

adverse effects (Figure 2)

3 DISCUSSION

Secukinumab is a human monoclonal

immunoglobulin (Ig) G antibody targeting IL-17A,

and has indication for both psoriasis and psoriatic

arthritis (Beecker & Joo, 2018).

The recommended

dose for adult with moderate psoriasis is 300 mg

subcutaneously at weeks 0,1,2,3 followed by 300 mg

1d 1c

1g 1j

Secukinumab for Psoriasis Treatment: A Case Series

497

Figure 2. (2a-2e) clinical features at baseline (2f-2j) clinical features at weeks 16.

every 4 weeks starting from weeks 4 (Beecker &

Joo, 2018).

In the case 1, the patient was treated by

secukinumab after ineffective-3 months-treatment

with cyclosporine, after 16 weeks of treatment with

secukinumab, he almost reached PASI 75.This result

almost similar to Ohtsuki et al.(2017) which

reported 82.4% patients showed improvement of

PASI 75 at weeks 16 with 300 mg of secukinumab

after ineffective treatment of 12 weeks of

cyclosporine.

In this case, PASI 75 achieved at

weeks 16 may be related to dose of secukinumab.

In the case 2, the patient diagnosed with psoriasis

pustular, had a history of methylprednisolone

treatment for 6 months (unknown dose) and suffered

for a moon face and gastritis. She treated by 300 mg

of secukinumab showed an improvement of PASI

100 in weeks 16. Our result is similar with CLEAR

study that reported PASI 100 achieved at weeks 16

with secukinumab 300 mg (Thaci et al., 2015).

The patients had not reported any side effect of

secukinumab such as respiratory tract infection,

headache, nausea or neutropenia. Some study

reported the common adverse effects of secukinmab

such as nasopharyngitis, headache and nausea during

the 12 weeks induction and the entire treatment

(Roman et al., 2015). We prescribed the patients

with omeprazole to reduce the adverse effect.

Both of patients have an improvement in PASI at

weeks 16, but 300 mg of secukinumab seems more

superior to reduce PASI. Some study reported

efficacy of secukinumab 300 mg and 150 mg

compare to placebo showed a greater benefit with

achieving PASI 75 at weeks 12 than placebo (Xiong

et al., 2015).

Ohtsuki et al. (2014) reported PASI 90

achieved in 86.2% patients treated by secukinumab

150 mg compare to secukinumab 300 mg at weeks

12 but the meta analysis of four references study

reported the secukinumab 300 mg had more benefit

than the secukinumab 150 mg to achieve PASI 75

(Xiong et al., 2015).

4 CONCLUSION

The efficacy of secukinumab for treating psoriasis

vulgaris and psoriasis pustular should be considered.

There is no report about adverse effect in this study.

Clinical improvement of PASI 75 and PASI 100 can

be achieved within 12-16 weeks of treatment.

REFERENCES

Beecker, J., Joo, J. 2018. Treatment of Moderate to Severe

Psoriasis with High Dose (450-mg) Secukinumab:

Case Reports of Off Label Use. 22(1):86-88

Fala L, Writer M. Consentyx (Secukinnumab): First IL-

17A Antagonist Receives FDA Approval for Moderate

to Severe Plaque Psoriasis. Am Health Drug Benefits.

2016;9:60-63

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

498

Gudjonsson, J.E., Elder, J.T. Psoriasis. 2012. In: Wolff K,

Goldsmith LA, Katz SI, Gilchrest BA, Paller AS,

Lefel DJ, editors. Fitzpatrick’s Dermatology in

General Medicine. 8

ed. New York: McGraw Hill.

p.197-231.

Langley, R.G., Elewski, B.E., Lebwohl, M., Reich, K.,

Griffiths, C.E.M., Papp, K., Puig, L., Nakagawa, H.,

Spelman, L., Sigurgeirsson, B., Rivas, E., Tsai, T.-F.,

Wasel, N., Tyring, S., Salko, T., Hampele, I., Notter,

M., Karpov, A., Helou, S., Papavassilis, C., 2014.

Secukinumab in plaque psoriasis--results of two phase

3 trials. The New England journal of medicine 371,

326–338. doi:10.1056/NEJMoa1314258

Ohtsuki, M., Morita, A., Abe, M., Takahashi, H., Seko, N.,

Karpov, A., Shima, T., Papavassilis, C., Nakagawa,

H., 2014. Secukinumab efficacy and safety in

Japanese patients with moderate-to-severe plaque

psoriasis: Subanalysis from ERASURE, a randomized,

placebo-controlled, phase 3 study. The Journal of

Dermatology 41, 1039–1046. doi:10.1111/1346-

8138.12668

Ohtsuki, M., Morita, A., Igarashi, A., Imafuku, S., Tada,

Y., Fujita, H., Fujishige, A., Yamaguchi, M., Teshima,

R., Tani, Y., Nakagawa, H., 2017. Secukinumab

improves psoriasis symptoms in patients with

inadequate response to cyclosporine A: A prospective

study to evaluate direct switch. Journal of

Dermatology 44, 1105–1111. doi:10.1111/1346-

8138.13911

Roman, M., Madkan, V.K., Chiu, M.W., 2015. Profile of

secukinumab in the treatment of psoriasis: Current

perspectives. Therapeutics and Clinical Risk

Management. doi:10.2147/TCRM.S79053

Thaçi, D., Blauvelt, A., Reich, K., Tsai, T.F., Vanaclocha,

F., Kingo, K., Ziv, M., Pinter, A., Hugot, S., You, R.,

Milutinovic, M., 2015. Secukinumab is superior to

ustekinumab in clearing skin of subjects with

moderate to severe plaque psoriasis: CLEAR, a

randomized controlled trial. Journal of the American

Academy of Dermatology 73, 400–409.

doi:10.1016/j.jaad.2015.05.013

Xiong, H.-Z., Gu, J.-Y., He, Z.-G., Chen, W.-J., Zhang,

X., Wang, J.-Y., Shi, Y.-L., 2015. Efficacy and safety

of secukinumab in the treatment of moderate to severe

plaque psoriasis: a meta-analysis of randomized

controlled trials. International journal of clinical and

experimental medicine 8, 3156–72.

Yeung J, Valbuena V. Successful Use of Secukinumab in

Pustular Psoriasis. JAAD Case Rep. 2016;2(6):470-2

Secukinumab for Psoriasis Treatment: A Case Series

499