BACKGROUND: Biologics have greatly improved psoriasis management. However, primary and secondary non-response to treatment requires innovative strategies to optimize outcomes. OBJECTIVE: To describe the use of combined treatment of biologics with conventional systemic agents or phototherapy in daily clinical practice. METHODS: We collected data on frequency of use, demographics, treatment characteristics and drug survival of biologics combined with conventional systemic agents or phototherapy in five PSONET registries. RESULTS: Of 9922 biologic treatment cycles, 982 (9.9%) were identified as combination treatment. 72.9% of treatment cycles concerned concomitant use of methotrexate, 25.3% concerned concomitant UVB therapy, acitretin or cyclosporin and 1.8% concerned combined treatment with PUVA, fumaric acids or a second biologic. Substantial variation was detected in type and frequency of combination treatments prescribed across registries. Patients initiated on combined treatment had generally severe disease and were affected with psoriasis for many years. The extent to which patients had been priory treated with biologic monotherapy and the proportion of patients affected with psoriatic arthritis differed between registries. Survival rates for etanercept, adalimumab, infliximab and ustekinumab with methotrexate ranged between 43 and 92%, 28 and 83%, 65 and 87% and 53 and 77%, respectively, across registries after one year with no consistent superior survival for a particular biologic. Longest survival on a biologic combined with methotrexate, acitretin or cyclosporin was 103, 78 and 34 months, respectively. CONCLUSION: Methotrexate was the most commonly used concomitant treatment for patients on a biologic. Wide geographical variations in treatment selection and persistence of combination treatment exist. Data derived from ongoing studies may help to determine whether combined treatment is superior to biologic monotherapy.

Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA

Centro Studi GISED Fondazione per la Ricerca Ospedale Maggiore Bergamo Italy

Department of Clinical Epidemiology Biostatistics and Bioinformatics Academic Medical Center University of Amsterdam Amsterdam The Netherlands

Department of Dermatology Academic Medical Center University of Amsterdam Amsterdam The Netherlands

Department of Dermatology Medical University of Graz Graz Austria

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

Department of Dermatovenereology Charles University 1st Faculty of Medicine and General University Hospital Prague Czech Republic

Department of Epidemiology Servizio Sanitario Regionale Regione Lazio Italy

Department of Quality Measurements and Research Clalit Health Services Tel Aviv Israel

Dermatology Department Inselspital University Hospital Bern Switzerland

Institute for Medical Informatics Statistics and Documentation Medical University of Graz Graz Austria

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