When Is It Time to Switch Biologics for Psoriasis?

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Biologics are a major advance in psoriasis treatment. “They change patients’ lives,” says Larry Green, M.D., a dermatologist in Rockville, Maryland. “And they’re much safer than anything we had before for people with severe psoriasis.”

These medications are a newer type of psoriasis drug. Unlike most drugs, which are made from chemicals, biologics are made from proteins produced by living cells. They target specific immune system processes that play a role in psoriasis.

Psoriasis: Why Switching to Another Biologic Can Help

Certain older medications, such as methotrexate and cyclosporine, also act on the immune system. But they have a less targeted effect, and they can also cause side effects elsewhere in the body.

Biologics are a big step forward in treatment. Yet people vary in their response to different biologics. To find the best one for you, it’s crucial to work closely with your doctor. Below are some things to consider and discuss.

Two Modes of Action

Two types of biologics are used to treat psoriasis:

  • Tumor necrosis factor (TNF)-alpha blockers: TNF-alpha is a chemical messenger in the immune system. It causes cells to release proteins that add to the inflammation underlying psoriasis. These medications block TNF-alpha. They include adalimumab (Humira), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade).

  • Interleukin (IL)-12/17A/23: This type of medication targets IL-12, IL-17A,and IL-23, proteins produced by immune cells. By keeping these proteins from attaching to other cells, it reduces inflammation. There are currently three IL-12/17A/23 medication son the market in the United States: ustekinumab (Stelara), secukinumab (Cosentyx), and brodalumab (Siliq).

Some people with psoriasis respond better to TNF-alpha blockers, and others to IL-12/17A/23. “We don’t know yet why certain medications work for some people better than others,” says Dr. Green. “So there is still an element of trial and error at this point. You put the person on whatever they seem most comfortable with or whatever best fits their lifestyle.” If that medication doesn’t work well for them, a switch to a different biologic sometimes helps.

Factors to Consider

Besides mode of action, biologics differ in several other respects. Here are some key differences to discuss with your doctor:

How it’s taken and how often. With Enbrel, Humira, and Simponi, you give yourself injections. Depending on the medication, the frequency varies from once a week to once a month.

Remicade is taken by IV infusion in a doctor’s office. After three initial infusions, you get them every eight weeks.

Stelara is injected by a health provider. After the first two shots, the injections are spaced 12 weeks apart.

How fast you’ll see results. “Remicade works the fastest because it’s intravenous. You’ll probably see benefits in two to three weeks,” Dr. Green says. “With the other biologics, it may take two to three months.” And you might need even longer to reach the maximum effect. So whichever biologic you choose, give it time to work. “You want to make sure the medication is working as well as it can be,” says Dr. Green.

How long the effects last. Stelara has the longest-lasting effects, and that can be either a pro or a con. “You only have to take Stelara four times a year because it lasts in your body much longer,” says Dr. Green. “But there are times when you might not want the medicine to last so long—for example, if you’re going to have surgery. In that case, something you give yourself once a week would be a better choice.”

Who shouldn’t take it. “If you have tuberculosis, an active infection, or a new cancer, you shouldn’t be taking any biologic,” says Dr. Green. “Beyond that, if you have a personal or family history of myasthenia gravis or multiple sclerosis, you can’t take TNF-alpha blockers, so you’re steered toward Stelara. But if you have a history of heart disease, extreme caution is needed with Stelara.”

Time for a Change?

TNF-alpha blockers have a lengthy track record. “Stelara is the newest addition to the field, so it hasn’t been proven as long,” Dr. Green says. “However, it’s recommended as a first-line therapy just like the TNF-alpha blockers are.

“For whatever reason, some people eventually find that one biologic doesn’t work anymore or never did work,” says Dr. Green. “But they may do better on a biologic with a different mechanism of action.” That’s when it’s good to have choices.

Key Takeaways

  • Biologics are a major advance in psoriasis treatment. These medications target specific immune system processes that play a role in psoriasis.

  • Two types of biologics are used to treat psoriasis: tumor necrosis factor (TNF)-alpha blockers and interleukin (IL)-12/17A/23.

  • If one type of biologic doesn’t work well for you, a switch to a different one sometimes helps.

  • Considerations include how the drug is administered, how fast you’ll see results, how long the effects last, and your current health.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2019 Aug 21

  1. Questions and Answers About Psoriasis. National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/Health_Info/Psoriasis/default.asp

  2. Moderate to Severe Psoriasis: Biologic Drugs. National Psoriasis Foundation.   https://www.psoriasis.org/about-psoriasis/treatments/biologics

  3. Biologic Drugs: Fact Sheets. National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/treatments/biologics/resources

  4. Psoriasis Treatments. National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/treatments

  5. Stelara (Ustekinumab). National Psoriasis Foundation. https://www.psoriasis.org/content/stelara-ustekinumab

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