Combining etanercept with traditional agents in the treatment of psoriasis: a review of the clinical evidence

Abstract

Psoriasis is a chronic, systemic inflammatory disorder manifesting primarily in skin and potentially in joints, frequently necessitating treatment with conventional systemic therapies, phototherapy or biological agents. Patients with moderate to severe disease suffer a diminished quality of life, experience significant comorbidities and have a higher mortality. Although traditional treatments are effective in the short-term, their use is often limited by concerns over long-term toxicity, including end-organ damage and risk of malignancy. Combination therapy is a commonly used approach and is often more effective than any single agent. Lower doses of two treatments in combination can also minimize potential side effects from a single agent at higher doses. Etanercept is a recombinant human tumour necrosis factor (TNF)α receptor (p75) protein fused with the Fc portion of IgG1 that binds to TNFα. This article reviews the evidence on the efficacy and safety of etanercept in combination with methotrexate, acitretin, narrowband UVB and cyclosporin. The largest body of evidence assesses the combination with methotrexate, although evidence is available for the other combinations. Data suggest that although highly effective as monotherapy, etanercept in combination with a conventional systemic agent can enhance efficacy and allow drug sparing. Potentially, the combination may also result in faster treatment responses and permit safe transitioning from one systemic agent to another. Evidence to date suggests that these benefits can be achieved without significant additional toxicity, although long-term data on the efficacy and safety of the combination in psoriatic populations is limited and further evaluation is warranted.

Combination of Etanercept and Twice-Weekly Administration of Cyclosporin in Psoriasis Unsatisfactorily Controlled by Etanercept Monotherapy: A Retrospective Analysis

“…Most reports evaluating etanercept/CsA combination in psoriasis patients have concerned' transition from CsA to etanercept treatment in patients requiring CsA discontinuation (6).…”

“…Compared to M1X, even more limited information exists on the role of cyclosporine (CsA) as a part of the combination strategy (6,7).…”

Biotech on the Rise: The Treatment of Psoriasis with Biological Drugs

“…Although highly effective as monotherapy, few studies have been published on the combination of etanercept with cyclosporine, narrowband UVB, acitretin and methotrexate (reviewed in Foley et al, 2010). Preliminary data from short-term analysis support the use of etanercept in combination therapy which does not seem to be associated with additional toxicities.…”

Etanercept in the Treatment of Psoriasis: The Emerging Evidence of its Therapeutic Value

“…The evidence of the efficacy and safety of this combined treatment is also confirmed by various case series in high-need psoriatic patients 38 and in the EASE study. 39 This latter was a multi-centre, randomized, openlabel trial which matched continuous and intermittent etanercept therapy in psoriatic patients. In this study, subjects who had been on a stable dose of MTX inferior to 20 mg weekly were permitted to continue their treatment when enrolled.…”