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Can Psoriasis Patients with Depression be Effectively Treated with Brodalumab? An Expert Consensus

Article: Expert Panel Discussion among Psoriasis and Psychodermatology Specialists: How Best to Manage Depressed Psoriasis Patients with Brodalumab

Treatment of psoriasis with biologics does not increase or cause depression but instead plays an important role in improving depression. The experts agree that it’s the disease, not the drug!”
— Quinn Thibodeaux, MD
NEW YORK CITY, NY, UNITED STATES, December 4, 2019 / -- Patients with psoriasis often have associated depression because of their perceived self-image. For this reason, brodalumab (Siliq), a biologic drug used to treat moderate to severe psoriasis, has been loosely associated with suicide, which has made clinicians hesitant to prescribe this highly effective medication.

Psoriasis is an immune-mediated chronic inflammatory disease that affects 8 million people in the United States and upwards of 3% of people worldwide. This disease manifests as unsightly raised, red, scaly plaques on the skin that often cause significant discomfort. Nearly 60% of people with psoriasis reported their disease to be a large problem in their everyday life. Furthermore, the negative physical, social, and psychiatric consequences of psoriasis pose a significant economic burden. Over the last decade, there have been meaningful advancements in the management of psoriasis through biologics, i.e. immune-modulating drugs. Brodalumab, an IL-17a receptor inhibitor, has been shown to quickly and effectively manage symptoms. However, because 4 suicides were recorded during phase III trials, a black box warning regarding suicidal ideation and behavior was applied.

Dr. Quinn Thibodeaux at the University of California, San Francisco, and colleagues note that depression is a well-established comorbidity of psoriasis and that some providers may resort to more conservative treatment plans for depressed patients with psoriatic disease. This may be especially true for management regimens that include brodalumab. In cases where depression is directly associated with the disease, patients would likely benefit from early treatment with drugs that are more effective and have a rapid onset.

The authors highlight the fact that even though the FDA attached a black label warning to brodalumab that they also concluded that the “causal association between treatment with brodalumab and increased risk of suicidal ideation and behavior has not been established.” Patients with moderate to severe psoriasis deserve management options that allow them to resolve symptoms quickly and effectively; biologics offer the opportunity for patients to experience improvement in their skin and, subsequently, in their disease-related depression. Prior to this expert panel, there were no practical strategies for appropriate usage beyond the limitations suggested by the package insert. For this reason, a distinguished group of experts was assembled to engage in meaningful discussion about how practicing clinicians can optimize the management of psoriasis amid disease-related depression.

The expert panel was tasked with formulating recommendations to help practitioners navigate concerns regarding aggressive systemic therapy for depressed psoriasis patients. The panel generated two recommendations: 1) dermatologists should properly screen for depression, attempt to determine if the depression is secondary to psoriasis, and refer to a mental health provider if necessary; 2) once a proper referral has been considered, highly effective and quickly acting treatments, such as IL-17 inhibitors (e.g. brodalumab) are preferred. The panel concluded that clinicians should always evaluate and consider patients’ mental health and that treatment of psoriasis with biologics does not increase or cause depression but instead plays an important role in ameliorating depression. Ultimately, the experts agreed that “it’s the disease, not the drug,” and they recognize that timely institution of highly and rapidly effective treatment may be critical in patients with significant negative psychological consequences of psoriasis.

Dr. Thibodeaux and the expert panel hope that this consensus statement will help to mitigate any concerns clinicians may have when contemplating brodalumab as an effective treatment for the depressed psoriasis patient.

SKIN: The Journal of Cutaneous Medicine® is a peer-reviewed online medical journal that is the official journal of The National Society for Cutaneous Medicine. The mission of SKIN is to provide an enhanced and accelerated route to disseminate new dermatologic knowledge for all aspects of cutaneous disease.

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(DOI: 10.25251/skin.3.6.1)

Quinn Thibodeaux, MD
University of California, San Francisco, Dept of Dermatology
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