BACKGROUND: Drug survival, defined as the length of time from initiation to discontinuation of a given therapy, allows comparisons between drugs, helps to predict patient's likelihood of remaining on a specific treatment, and achieving the best decision for each patient in daily clinical practice. OBJECTIVE: The aim of this study was to provide data on drug survival of secukinumab, ixekizumab, brodalumab, guselkumab, tildrakizumab, and risankizumab in a large international cohort, and to identify clinical predictors that might have an impact on the drug survival of these drugs. METHODS: This was a retrospective, multicentric, multi-country study that provides data of adult patients with moderate to severe psoriasis who started treatment with an interleukin (IL)-17 or IL-23 inhibitor between 1 February 2015 and 31 October 2021. Data were collected from 19 distinct hospital and non-hospital-based dermatology centers from Canada, Czech Republic, Italy, Greece, Portugal, Spain, and Switzerland. Kaplan-Meier estimator and proportional hazard Cox regression models were used for drug survival analysis. RESULTS: A total of 4866 treatment courses (4178 patients)-overall time of exposure of 9500 patient-years-were included in this study, with 3164 corresponding to an IL-17 inhibitor (secukinumab, ixekizumab, brodalumab) and 1702 corresponding to an IL-23 inhibitor (guselkumab, risankizumab, tildrakizumab). IL-23 inhibitors had the highest drug survival rates during the entire study period. After 24 months of treatment, the cumulative probabilities of drug survival were 0.92 (95% confidence interval [CI] 0.89-0.95) for risankizumab, 0.90 (95% CI 0.88-0.92) for guselkumab, 0.80 (95% CI 0.76-0.84) for brodalumab, 0.79 (95% CI 0.76-0.82) for ixekizumab, and 0.75 (95% CI 0.73-0.77) for secukinumab. At 36 months, only guselkumab [0.88 (95% CI 0.85-0.91)], ixekizumab [0.73 (95% CI 0.70-0.76)], and secukinumab [0.67 (95% CI 0.65-0.70)] had more than 40 patients at risk of drug discontinuation. Only two drugs had more than 40 patients at risk of drug discontinuation at 48 months, with ixekizumab demonstrating to have a higher cumulative probability of drug survival [0.71 (95% CI 0.68-0.75)] when compared with secukinumab [0.63 (95% CI 0.60-0.66)]. Secondary failure was the main cause for drug discontinuation. According to the final multivariable model, patients receiving risankizumab, guselkumab, and ixekizumab were significantly less likely to discontinue treatment than those receiving secukinumab. Previous exposure to biologic agents, absent family history of psoriasis, higher baseline body mass index (BMI), and higher baseline Psoriasis Area and Severity Index (PASI) were identified as predictors of drug discontinuation. CONCLUSION: The cumulative probability of drug survival of both IL-17 and IL-23 inhibitors was higher than 75% at 24 months, with risankizumab and guselkumab demonstrating to have overall cumulative probabilities ≥ 90%. Biological agent chosen, prior exposure to biologic agents, higher baseline BMI and PASI values, and absence of family history of psoriasis were identified as predictors for drug discontinuation. Risankizumab, guselkumab, and ixekizumab were less likely to be discontinued than secukinumab.

1st Departament of Dermatology Venereology Faculty of Medicine National and Kapodistrian University of Athens A Sygros Hospital for Skin and Venereal Diseases Athens Greece

2nd Department of Dermatology Venereology Aristotle University School of Medicine Thessaloniki Greece

Center for Health Technology and Services Research Porto Portugal

Clínica Médica Belém Lisbon Portugal

Department of Dermatological Science Section of Dermatology University of Florence Florence Italy

Department of Dermatology Centro Hospitalar Universitário do Porto Porto Portugal

Department of Dermatology Germans Trias i Pujol University Hospital Badalona Spain

Department of Dermatology Hospital de la Santa Creu i Sant Pau Barcelona Spain

Department of Dermatology Lausanne University Hospital CHUV and University of Lausanne Lausanne Switzerland

Department of Dermatology University of Pisa Pisa Italy

Department of Dermatovenereology 3rd Faculty of Medicine Charles University and Kralovske Vinohrady University Hospital Prague Czech Republic

Department of Medicine Section of Dermatology and Venereology University of Verona Verona Italy

Dermatologia Dipartimento di Medicina e Chirurgia Traslazionale Università Cattolica Del Sacro Cuore Rome Italy

Dermatology Department Hospital Universitario de la Princesa Instituto de Investigación Sanitaria La Princesa Madrid Spain

Dermatology Department University of Brescia ASST Spedali Civili of Brescia Brescia Italy

Dermatology Unit Department of Medicine University of Padua 35128 Padua Italy

Division of Dermatology Department of Medicine University of Toronto Probity Medical Research Waterloo ON Canada

Hospital CUF Descobertas Lisbon Portugal

Instituto de Ciências Biomédicas Abel Salazar University of Porto Porto Portugal

McMaster University Hamilton ON Canada

The Lynde Institute for Dermatology Department of Medicine University of Toronto Toronto Canada

Unit of Dermatology University of Campania Luigi Vanvitelli Naples Italy

UOC di Dermatologia Dipartimento di Scienze Mediche e Chirurgiche Fondazione Policlinico Universitario A Gemelli IRCCS Rome Italy

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