First-Line Biologics in Psoriasis: Evidence from the BADBIR Cohort Study

Psoriasis is a chronic inflammatory disease that can alter an individual’s life course, causing physical and emotional effects and reducing quality of life. It is associated with cardiovascular comorbidities and increased cardiovascular mortality and is related to other comorbidities such as inflammatory bowel disease, malignancy, obesity, and mood disorders. ¹

Moderate to severe psoriasis is usually treated with systemic therapies, but most guidelines suggest starting treatment with conventional systemic drugs. Biologic therapies that are more effective, safer, and faster to improve patients’ outcomes are frequently considered second-line options solely because of cost. ^2,3 The appearance of biosimilar therapies has improved access to biologic therapy by lowering the cost of psoriasis treatment. Some authors have also demonstrated faster responses with biologics as first-line treatments, proposing a step-down rather than a step-up approach. ⁴

The study published by Phan and colleagues is a cohort study that follows the target trial emulation framework and uses data from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR). This registry includes patients treated with biologic and non-biologic systemic therapies for psoriasis since 2007. The emulated trial was a randomized, open-label study of adults (≥18 years) with moderate to severe plaque psoriasis (Psoriasis Area and Severity Index 10 [PASI] ≥10), comparing first-line biologic therapy with first-line conventional systemic therapies (methotrexate, ciclosporin, or acitretin).

The primary outcome was the change in PASI over 5 years of follow-up, and the secondary outcomes were time to first achievement of complete skin clearance (PASI = 0), change in the Dermatology Life Quality Index (DLQI), and time to first newly diagnosed chronic comorbidities. They fitted pooled weighted logistic regression models, which approximate the discrete-time hazard ratio, to estimate time-to-event outcomes: (i) achieving complete skin clearance (PASI = 0), and (ii) development of chronic comorbidities. The study included 3,702 patients: 3,368 received standard of care, and 334 initiated a biologic as their first-line systemic treatment.

The patients starting with a biologic were older, had more comorbidities, and were more likely to have psoriatic arthritis. They also had longer disease duration and higher PASI. The first treatment change occurred earlier in patients receiving standard of care than in those receiving biologics (13.3 months vs 19.9 months). Patients starting first-line biologic therapy had lower PASI at 1 (2.4 vs 6.7) and 5 (2.0 vs 4.7) years, and lower DLQI at 1 (4.0 vs 7.9) and 5 (3.5 vs 5.3) years, and had a lower risk of developing new chronic comorbidities over five years. The rate of achieving PASI 0 was 58.6% in patients starting biologics, compared with 32.1% in patients following conventional treatment, and the mean time to PASI 0 was 13.3 months in patients receiving first-line biologics vs 23.3 months in patients receiving standard-of-care treatment.

Patients with moderate to severe psoriasis often require multiple treatment options with slow onset of action and lower efficacy, resulting in cumulative waiting times to clear psoriasis.⁵ Delaying effective treatment promotes cumulative life impairment, the development of comorbidities, and unhealthy behaviors like smoking and alcohol consumption. Rapid and almost clearance responses have been identified as a crucial outcome for patients.⁶

On the other hand, there is growing evidence that early intervention with highly effective treatments may reduce the incidence of comorbidities, lower long-term disease burden, and improve disease control⁷. Treatment sequences that start with nonbiological agents appear to be associated with lower time-effectiveness ratios. In contrast, initiating biologics as first-line systemic treatment for moderate to severe psoriasis is associated with greater clinical improvement, higher rates of complete skin clearance, and a lower risk of chronic comorbidities over five years, compared with the current standard-of-care approach. Patients who start with conventional treatments often experience longer periods of suboptimal disease control, undergo more frequent switching and cycling, and face delays in achieving standard therapeutic targets.⁸

This emerging evidence supports improving access to biologics as first-line treatment and exploring alternative cost-reduction strategies, such as dose de-escalation once therapeutic goals have been achieved. ⁹