title: Use of biologic therapeutics in difficult-to-treat psoriasis.
abstract: BACKGROUND
  A need for improved psoriasis management drove the development of four biologicals now approved for use in moderate to severe psoriasis: alefacept, efalizumab, etanercept, and infliximab.
  
  
  OBJECTIVE
  This review compares the recommended and practical use of biologicals in "difficult-to-treat" psoriasis. Difficult-to-treat patients, a subpopulation of particular interest to caregivers and regulators, are those for whom conventional options are unavailable, contraindicated, intolerable, or ineffective.
  
  
  CONCLUSIONS
  Despite guidance recommending that biologicals be considered among first-line antipsoriasis treatments, formulary inclusion may be influenced by the biologicals' success in controlling difficult-to-treat psoriasis. Findings from the Clinical Experience Acquired with Raptiva (CLEAR) randomized controlled trial (RCT) established efalizumab's equal efficacy in difficult-to-treat and moderate to severe psoriasis. The CLEAR data were cited in support of a regulatory recommendation to include efalizumab in Canadian provincial formularies. For some other biologicals, evidence regarding efficacy in difficult-to-treat psoriasis remains equivocal. Additional RCTs are needed to define appropriate roles for specific biologicals in difficult-to-treat patients.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON. derma@lynderm.com
authors.forename: Charles
authors.initials: C
authors.lastname: Lynde
mesh_terms: D000077944:Alefacept; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized; D002170:Canada; D003879:Dermatologic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000068800:Etanercept; D005569:Formularies as Topic; D017408:Guidelines as Topic; D006801:Humans; D007074:Immunoglobulin G / Q000008:administration & dosage / Q000627:therapeutic use; D000069285:Infliximab; D018579:Patient Selection; D011565:Psoriasis / Q000188:drug therapy*; D018124:Receptors, Tumor Necrosis Factor / Q000008:administration & dosage / Q000627:therapeutic use; D011993:Recombinant Fusion Proteins / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D003879:Dermatologic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D011993:Recombinant Fusion Proteins; D000069285:Infliximab; D000077944:Alefacept; D000068800:Etanercept; C472181:efalizumab