International Psoriasis Council

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Advancing Knowledge. Improving Care.

Commentary: Looking Beyond Plaque Psoriasis: Novel IL-36 Inhibitor for Prevention of Generalized Pustular Psoriasis Flares

Blog - Commentary - Alexander Egeberg - graphic

Alexander Egeberg, MD, PhD, DMSc

University of Copenhagen and Bispebjerg Hospital

Copenhagen, Denmark

Bio

PUBLICATIONS

Efficacy and Safety of Subcutaneous Spesolimab for the Prevention of Generalised Pustular Psoriasis Flares (Effisayil 2): An International, Multicentre, Randomised, Placebo-controlled Trial. Morita A, Strober B, Burden AD, et al. Lancet. 2023 Oct 28;402(10412):1541-1551. doi: 10.1016/S0140-6736(23)01378-8. Epub 2023 Sep 19. PMID: 37738999.

Why this article was chosen

Generalized pustular psoriasis (GPP) is a disease with limited effective treatment options. Regulatory authorities, including the European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA), have approved intravenously delivered spesolimab for the treatment of acute flares of GPP. Recently, a 48-week study examined the efficacy and safety of subcutaneous delivery of spesolimab to prevent GPP flares. The results support using spesolimab for long-term treatment in patients with GPP.

Commentary

Recent decades have seen extraordinary advances and approvals of new therapies for plaque psoriasis, with specific IL-17 and IL-23 inhibitors, biosimilars, and, most recently, novel oral therapies such as TYK-2 inhibitors becoming available.

Nevertheless, patients with other psoriasis subtypes, particularly pustular forms, face more significant treatment challenges, and therapeutic options in these cases remain limited. GPP is a rare and potentially life-threatening condition characterized by the rapid development of sterile pustules on the skin and often accompanied by systemic symptoms. Flares of GPP are unpredictable and have historically necessitated hospitalization for extended periods, with a significant mortality rate of up to 7% during hospitalization or within a year post-discharge.1

However, recent advancements in GPP treatment include the approval of IL-23 inhibitors in select Asian countries and the development of targeted biologics such as spesolimab and imsidolimab specifically for GPP.2 These drugs involve direct inhibition of the IL-36 receptor, which is of particular interest since dysregulation of the IL-36 pathway occurs in many, but not all, GPP cases.3, 4

The EMA and FDA approvals of intravenous spesolimab for GPP flares marked a significant advancement in the treatment landscape for GPP. Clinical trials and emerging research have shown promising results, demonstrating safety and efficacy in managing this challenging condition. However, since few dermatologists provide intravenous infusions in their clinics, this may limit its use in specialized clinics and in-patient settings.

The present study assessed several doses of subcutaneous spesolimab prevention of GPP flares.5 Over the course of 48 weeks, significantly fewer patients treated subcutaneously with high-dose spesolimab (600 mg loading dose followed by 300 mg every four weeks) developed GPP flares (n=3 [10%]) compared with the placebo group (n=16 [52%]). The study also noted an absence of flares from week 4 through week 48 in the high-dose group, albeit with a higher incidence of serious adverse events compared to placebo (10% vs. 3%).

This study is valuable considering the underserved GPP patient population. A subcutaneous formulation of spesolimab could offer a more convenient treatment approach, and the study underscores the importance of a proactive treatment approach to prevent flares.

Nonetheless, the balance between treatment efficacy and safety remains crucial, particularly considering the multiple comorbidities seen in GPP patients.1 Moreover, while promising for GPP, trials have revealed spesolimab’s inefficacy for other psoriasis subtypes, such as palmoplantar pustulosis (PPP), leaving this variant with substantial unmet medical needs.6 Thus, while these findings are promising for a subset of psoriasis patients, there is still much to be done for our patients with pustular forms of psoriasis.

References

  1. Characteristics and Prognosis in First-Time Hospitalized Generalized Pustular Psoriasis Patients: Insights from National Databases. Haugaard JH, Thein D, Egeberg A. Br J Dermatol. 2023 Oct 7:ljad384. doi: 10.1093/bjd/ljad384. Epub ahead of print. PMID: 37804532.
  2. A Review of the Clinical Trial Landscape in Psoriasis: An Update for Clinicians. Dermatol Ther (Heidelb). Drakos A, Vender R. 2022 Dec;12(12):2715-2730. doi: 10.1007/s13555-022-00840-9. Epub 2022 Nov 1. PMID: 36319883; PMCID: PMC9674811.
  3. Psoriasis Pathogenesis and the Development of Novel Targeted Immune Therapies. Hawkes JE, Chan TC, Krueger JG. J Allergy Clin Immunol. 2017 Sep;140(3):645-653. doi: 10.1016/j.jaci.2017.07.004. PMID: 28887948; PMCID: PMC5600287.
  4. An Update on Generalized Pustular Psoriasis. Gooderham MJ, Van Voorhees AS, Lebwohl MG. Expert Rev Clin Immunol. 2019 Sep;15(9):907-919. doi: 10.1080/1744666X.2019.1648209. Epub 2019 Sep 5. PMID: 31486687.
  5. Efficacy and Safety of Subcutaneous Spesolimab for the Prevention of Generalised Pustular Psoriasis Flares (Effisayil 2): An International, Multicentre, Randomised, Placebo-Controlled Trial. Morita A, Strober B, Burden AD, et al. Lancet. 2023 Oct 28;402(10412):1541-1551. doi: 10.1016/S0140-6736(23)01378-8. Epub 2023 Sep 19. PMID: 37738999.
  6. Spesolimab Efficacy and Safety in Patients with Moderate-to-Severe Palmoplantar Pustulosis: A Multicentre, Double-Blind, Randomised, Placebo-Controlled, Phase IIb, Dose-Finding Study. Burden AD, Bissonnette R, Navarini AA, et al. Dermatol Ther (Heidelb). 2023 Oct;13(10):2279-2297. doi: 10.1007/s13555-023-01002-1. Epub 2023 Sep 20. PMID: 37731086; PMCID: PMC10539230.

2 thoughts on “Commentary: Looking Beyond Plaque Psoriasis: Novel IL-36 Inhibitor for Prevention of Generalized Pustular Psoriasis Flares

  1. Natasa Djuricanin says:

    Hi! How many patients do you have that are treated with spesolimab? What kind of side effects did you have in those cases? Who are the patients which are candidates for this kind of therapy?

  2. Alexander Egeberg says:

    Personally, I have only used spesolimab on one patient so far, as GPP is (fortunately) a very rare condition. The patient was a middle-aged man with no major medical issues aside from GPP and arthritis, and he did not experience any side effects during or after the infusion.
    So far, the drug is only approved for the treatment of flares of GPP, but criteria may differ between countries and healthcare systems. At the time, I was only able to use it because the patient had previously experienced side effects of cyclosporine – otherwise, I would have had to use that.
    Specific information about the use of spesolimab, and its contraindications, can be found here: https://www.ema.europa.eu/en/documents/product-information/spevigo-epar-product-information_en.pdf

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