title: Sequential treatment with biologics: switching from efalizumab to etanercept in 35 patients with high-need psoriasis.
abstract: BACKGROUND
  Use of biological agents has been shown to be an efficacious approach in psoriasis, when traditional treatments fail. However, there are limited data on the effectiveness and safety of switching from one biological agent to another.
  
  
  OBJECTIVE
  We aimed to evaluate the effectiveness and safety of etanercept as a sequential treatment in patients previously treated with efalizumab, and to evaluate different transition strategies from efalizumab to etanercept.
  
  
  METHODS
  We present a retrospective study in patients with high-need plaque psoriasis who were unable to continue efalizumab and were immediately switched to etanercept.
  
  
  RESULTS
  We included 35 patients during a 4.5-year period. At 24 weeks of etanercept therapy, 57% of patients had a PASI reduction of 75%, suggesting that alternating between biological agents is feasible. We used three different switching approaches: (i) etanercept in combination with cyclosporine as bridge therapy, (ii) etanercept in combination with methotrexate as bridge therapy, (iii) etanercept monotherapy. Combination therapy was efficacious in all patients, including eight patients with rebound phenomenon with efalizumab. Etanercept was discontinued in two patients as a result of serious adverse events that consisted of an oral squamous cell carcinoma and a diffuse B-cell-non-Hodgkin lymphoma.
  
  
  CONCLUSIONS
  In our experience, it seems that etanercept alone may not be sufficient when transitioning from efalizumab in high-need patients with severe worsening or rebound of psoriasis. In such patients, combination of etanercept with cyclosporine or methotrexate is a more effective approach. Non-response to efalizumab did not preclude clinical response after switching to etanercept.
authors.affiliation: Psoriasis Unit, Department of Dermatology, University of Athens, Andreas Sygros Hospital, Athens, Greece. cliodes@hotmail.com
authors.forename: C
authors.initials: C
authors.lastname: Antoniou
authors.forename: C
authors.initials: C
authors.lastname: Dessinioti
authors.forename: T
authors.initials: T
authors.lastname: Vergou
authors.forename: A J
authors.initials: AJ
authors.lastname: Stratigos
authors.forename: G
authors.initials: G
authors.lastname: Avgerinou
authors.forename: M
authors.initials: M
authors.lastname: Kostaki
authors.forename: A
authors.initials: A
authors.lastname: Katsambas
mesh_terms: D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000008:administration & dosage / Q000627:therapeutic use*; D011565:Psoriasis / Q000188:drug therapy*; D018124:Receptors, Tumor Necrosis Factor / Q000008:administration & dosage / Q000627:therapeutic use*; D012189:Retrospective Studies
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D000068800:Etanercept; C472181:efalizumab