r e v b r a s r e u m a t o l . 2015;55(6):469–470
w w w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Editorial
A
new
era
in
psoriasis
and
psoriatic
arthritis
therapy:
new
mechanisms
of
action
and
the
introduction
of
biogeneric
drugs
Uma
nova
era
na
terapia
em
psoríase
e
artrite
psoriática:
novos
mecanismos
de
ac¸ão
e
a
introduc¸ão
de
biossimilares
Interleukin-17 is a proinflammatory cytokine that acts by increasingtheexpressionofchemokinesthatrecruit mono-cytesandneutrophilstothesiteofinflammation.Producedby helperTcellsubtypesandinducedbyotherinterleukin(IL23), IL17initiatesitsfunctionbyjoiningitselftoacellmembrane receptor(IL17R).1 Theneutralizationofthisfunctionbythe blockageofthisuniontothereceptor,orbytheadministration ofaspecificantibodyagainstinterleukin,entailsthe possibil-ityofanewbiologicaltreatmentofautoimmunediseasessuch asPsoriasisandPsoriaticArthritis.2,3
Theintroduction ofanewbiological,withanew mech-anism of action, means that the history of biological therapiesforpsoriasisandotherautoimmunediseases will be re-written. The neutralizing monoclonal antibody, IL17 (secukinumab),should beapprovedbyANVISA bythe end of2005orbeginningof2006.2USFoodandDrug Administra-tion(FDA)recommendedanalmostunanimousapprobation ofsecukinumabforthetreatmentofpsoriasis;andthisdrug wasapprovedmonthsagobytheEuropeanMedicinesAgency (EMA)underthetradename Cosentyx.Twootherbiological agentsshouldbecomewidelyavailablesoon:Ixekizumaband brodalumab,aanti-IL-17receptormonoclonalantibody.What drawsmoreattentioninthestudieswhichledtotheapproval ofanti-IL17isthatthosepapersthatcarriedouthead-to-head comparisonsbetweenetanerceptandustekinumab–which are partofthe standard therapy withbiologicalagents for psoriasis–showthatanti-IL17featureshavesuperiorclinical efficacyversusanti-TNFandanti-IL12-23.
Inastudyincluding1307patientsreceivingsecukinumab, theresponsetoanti-IL17wasmorerobustwhencomparedto etanercept.Whencomparedtoustekinumabafter4monthsin aphaseIIIstudy,mostofpatientsachievedPASI90inamore significantpercentage,whencomparedtothegrouptreated onlywithustekinumab.Similarlytowhatseemstooccurin patientswithrheumatoidarthritis, smallmoleculesshould
alsoplaya role inthetreatment ofpsoriasisand psoriatic arthritis.ThisisindeedthecaseofApremilast,aninhibitorof phosphodiesteraseandmodulatorofcAMPlevels,whichhas recentlybeenapprovedbyFDA.Oneaspectthatbroughtsome controversyregardingtheanalysisoftheclinicalstudieswas that,intheapprovalofthisagent,bodymasswasnot consid-ered(patientswithpsoriasistendtobeobesewhencompared toindividualsofthesameagebutwithoutpsoriasis).Theother aspecttoconsideristhat,evennotbeingabiologicalagent,but asyntheticone,pharmaceuticalcompaniesare introducing thedrugonthemarketwithpricessimilartothosepracticed forbiologicalagents.4–10 IL17isaproinflammatorycytokine that playsan important role in perpetuating the psoriatic plaque.ThereceptorforIL17canbefoundonthesurfaceof keratinocytes,anditsblockagereversesthehistopathologyof thepsoriaticlesion.Withanti-IL17,itispossibletoobtainan almostcompletewhiteningofskinlesions,besidesa simul-taneousimprovementoftheassociatedarthritis,especially if this isthe first biological used.Similarly towhat occurs inrheumatoidarthritisandpsoriasis,after3yearsof treat-ment,lessthan halfofthepatientswho hadbeen initially benefited withfavorable responsesstill present convincing clinicalresponses.Thisphenomenon,alsoknownas “biolog-icalfatigue”,seemstobecommoninrheumaticpatientsand withplaquepsoriasis.
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rev bras reumatol.2015;55(6):469–470afteroralmostsimultaneouslywiththeintroductionof anti-IL17forthetreatmentofinflammatoryimmunearthritis.11,12
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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1. MiossecP,KornT,KuchooUH.IL-17andtype17helperT
cells.NEnglJMed.2009;361:888–98.
2. MarinoniB,CeribelliA,MassarottiMS,SelmiC.Th17axisin
psoriaticdisease:pathogeneticandtherapeuticimplications.
AutoimmunHighlights.2014;5:9–19.
3. ChiricozziA,KruegerJG.IL-17targetedtherapiesfor
psoriasis.ExpertOpinInvestigDrugs.2013;22:993–1005.
4. LangleyRG,ElewskiBE,LabwholM,ReichK,GriffithsCEM,
PappK,etal.Secukinumabinplaquepsoriasis–resultsof
twophase3trials.NEnglJMed.2014;371:326–38.
5. GriffithsCEM,ReichK,LebwohlM,vandeKerkhofP,PaulC,
MenterA,etal.Comparisonofixekizumabwithetanerceptor
placeboinmoderate-to-severepsoriasis(UNCOVER-2and
UNCOVER-3):resultsfromtwophase3randomisedtrials.
Lancet.2015;386(9993):541–51.
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anti-IL17Rmonoclonalantibody,inPsoriaticArthritis.NEngl
JMed.2014;370:2295–306.
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etal.Secukinumabissuperiortoustekinumabinclearing
skinofsubjectswithmoderatetosevereplaquepsoriasis:
CLEAR:arandomizedcontrolledtrial.JAmAcadDermatol.
2015;73:400–9.
8.MeasePJ,ArmstrongAW.Managingpatientswithpsoriatic
disease:thediagnosisandpharmacologictreatmentof
psoriaticarthritisinpatientswithpsoriasis.Drugs.
2014;74:423–41.
9.ScheinbergM,GoldenbergJ,FeldmanDP,NóbregaJL.
Retrospectivestudyevaluatingdosestandardsforinfliximab
inpatientswithrheumatoidarthritisatHospitalIsraelita
AlbertEinstein,SãoPaulo,Brazil.ClinRheumatol.
2008;27:1049–52.
10.GolmiaRP,ScheinbergMA.Retentionratesofinfliximaband
tocilizumabduringa3-yearperiodinaBrazilianhospital.
Einstein(SaoPaulo).2013;11:492–4[English,Portuguese].
11.ScheinbergM,Casta ˜neda-HernándezG.Anti-tumornecrosis
factorpatentexpirationandtherisksofbiocopiesinclinical
practice.ArthritisResTher.2014;16:501.
12.ScheinbergM.Therapy:facinguptobiosimilaragents-the
ACRposition.NatRevRheumatol.2015;11:322–4.
MortonScheinberga,b aHospitalIsraelitaAlbertEinstein,SãoPaulo,SP,Brazil
bCenterforClinicalResearch,HospitalAACD,SãoPaulo,SP,Brazil
E-mail:morton@osite.com.br
2255-5021/©2015ElsevierEditoraLtda.Allrightsreserved.
