Effectiveness and Safety of Systemic Therapy for Psoriasis in Older Adults

Abstract

IMPORTANCETreating older adults with psoriasis can be challenging owing to comorbidities, concomitant medication use, and consequent safety risks. Although many studies focus on the effectiveness and safety of systemic antipsoriatic therapies in the general population, their effectiveness in older adults with psoriasis has not been systematically assessed.OBJECTIVE To evaluate the effectiveness and safety of systemic antipsoriatic therapies in patients 65 years or older.EVIDENCE REVIEW A systematic literature search was conducted in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) on November 11, 2019. No date limit was used. Randomized clinical trials, cohort studies, large case series, and meta-analyses assessing efficacy (or effectiveness) and/or safety of systemic antipsoriatic therapies in patients 65 years or older were included.FINDINGS The initial search yielded 11 096 results, of which 31 unique articles with 39 561 patients were included in analysis. Overall, limited data were available per systemic agent, and overall quality of the included studies on conventional systemic therapies was low. At the end of the induction phase (12-16 weeks after start of treatment), a reduction of 75% in Psoriasis Area and Severity Index was achieved in 49% of 74 methotrexate sodium users 65 years or older, 46% to 52.6% of 178 older cyclosporin users, 27% to 47.8% of 108 older acitretin users, 15.6% to 64% of 256 etanercept users 65 years or older, 66.7% to 93% of 43 infliximab users 65 years or older, 60.7% to 65% of 100 adalimumab users 65 years or older, 56.5% of 46 ustekinumab users 65 years or older, and 86.4% of 67 secukinumab users 65 years or older. Effectiveness of acitretin, etanercept, adalimumab, and secukinumab appeared not to be associated with age; studies regarding other systemic antipsoriatic therapies did not provide age group comparisons. Older age was significantly associated with renal function deterioration in cyclosporin users and with lymphopenia in fumaric acid esters users (hazard ratio, 2.42; 95% CI, 1.65-3.55; P < .001). Infections were the most frequently reported adverse event in patients 65 years or older using biologics, but no significant association with age was found.CONCLUSIONS AND RELEVANCE On the basis of limited available evidence, age alone should not be a limiting factor in psoriasis management. Awareness of comorbidities and concomitant medication use is very important, as well as appropriate dosing and frequent laboratory and clinical monitoring. More real-world evidence and (sub)analyses of prospective cohort studies on the effectiveness and safety of systemic therapies in older adults are critical to optimize personalized, effective, and safe antipsoriatic management in this growing patient group.

Use of Biological Treatments in Elderly Patients with Skin Psoriasis in the Real World

“…Due to the improvement in life expectancy, the prevalence of psoriasis is increasing in the elderly [22]. It is estimated that around 10% of patients with psoriasis belong to this group and 15% of these have moderate-severe psoriasis.…”

“…It is important to carry out many physical and analytical controls in the follow-up of patients treated with systemic drugs, and to make dose adjustments when required [22].…”

A case series of persistent lymphopaenia following treatment with fumaric acid esters for psoriasis

“…Suggested risk factors for the development of lymphopaenia include older age, longer duration of treatment with FAEs and low lymphocyte count on commencement of treatment 1 . A recent systematic review of the efficacy and safety of anti‐psoriatic agents in the treatment of adults aged >65 years highlighted that this cohort of patients are under‐represented in clinical trials, despite being at a higher risk of complications, including lymphopaenia, during treatment with FAEs 5 . Severe, grade 3 lymphopaenia is also more common in this cohort 6 .…”

Quality of life, treatment goals, preferences and satisfaction in older adults with psoriasis: a patient survey comparing age groups

“…Dear Editor , Psoriasis management in the rapidly expanding geriatric population can be complex owing to frailty, comorbidities, comedication and limited available data on treating older patients with psoriasis 1 . Previous studies reported comparable disease severity in patients aged ≥ 65 years and patients aged < 65 years, 2–4 although prescribed antipsoriatic therapies differed between age groups 2,3,5 .…”

“…Ultra-late recurrence, defined as recurrence after more than 15 disease-free years, is very rare. 1,2 This phenomenon is not well analysed because obtaining samples with intact DNA for detailed analyses of tumour tissue stored for such a long time has been considered impossible. Here we report a case of malignant melanoma with ultra-late recurrence 41 years after treatment.…”