Combining biologic therapieswith other systemic treatments in psoriasis: Evidence-based, best-practice recommendations from the medical board of the national psoriasis foundation

IMPORTANCE: While monotherapy with biologic agents is effective for many patients with psoriasis, some patients require combination therapy. Evidence-based recommendations on combination therapy provide guidance for treating appropriately selected patients with psoriasis. OBJECTIVE: To make evidence-based, best-practice recommendations regarding combining biologics with other systemic treatments, including phototherapy, oral medications, or other biologics, for psoriasis treatment. EVIDENCE REVIEW: We searched the MEDLINE database for studies from January 1, 1946, to June 18, 2013, that evaluated therapies combining biologics with phototherapy, oral medications, or other biologic agents. The Medical Board of the National Psoriasis Foundation arrived at best-practice recommendations through group discussion and voting. FINDINGS: Few trials evaluated the efficacy and safety of combination therapies in moderate to severe psoriasis. Combining biologics, such as etanercept or adalimumab, with phototherapy likely results in greater reduction in disease severity than either alone. Etanercept and methotrexate combination is more effective than monotherapy with either medication. A combination of infliximab with methotrexate results in greater efficacy than infliximab alone. With concomitant use of acitretin, the dosing of etanercept can be reduced to maintain similar levels of efficacy. Short-term cyclosporine use has been combined with etanercept or adalimumab to control psoriasis flares. Based on the expert opinion of the Medical Board of the National Psoriasis Foundation, the preferred order for combining a second modality with biologics is biologic and methotrexate combination, biologic and acitretin combination, and then biologic and phototherapy combination. In the psoriasis literature, there are overall insufficient data on combining biologics with acitretin, cyclosporine, or a second biologic. CONCLUSIONS AND RELEVANCE: Among appropriately selected patients with psoriasis, carefully chosen combinations may result in greater efficacy, while minimizing toxicity.