By Gary M. White, MD
Note: This is a summary only. Please consult the latest information when prescribing.
- Highly effective for psoriasis. PASI-75 of 80%.
- Proven effective for palmoplantar psoriasis [JAAD 2017;76;70].
- Subcutaneous injection with loading dose initially followed by monthly maintenance.
- Avoid in patients with Crohn's disease as can make worse.
- Candida infection has been seen in slightly higher percentages in patients treated with secukinumab.
- Before starting, ask patients if they are up-to-date with their vaccinations.
- No issue with cancer in the package insert. A prior history of cancer is not a contraindication.
- No need for blood monitoring required by the PI. (But you may get Quanterferon-Tb Gold yearly as your method of monitoring for Tb.)
- Moderate to severe psoriasis
- Psoriatic arthritis
- Ankylosing spondylitis
Warnings and Precautions
- Infections. Serious infections have occurred. Cosentyx may increase the risk of infections.
- Tuberculosis. Evaluate for Tb prior to therapy.
- Inflammatory Bowel Disease. Cases of IBD were observed in clinical trials.
- Hypersensitivity reaction. If anaphylaxis or other serious allergic reaction occurs, discontinue Cosentyx immediately and initiate appropriate therapy.
Live vaccines should not be given with Cosentyx. Prior to initiating therapy consider completion of all age appropriate immunizations. Patients may receive killed vaccines. However non-live vaccines given during the course of Cosentyx may not elicit an immune response sufficient to prevent disease.
Mechanism of Action
The European Commission has approved secukinumab as a first-line systemic treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy.
Dosing for and Use in Psoriasis
- The recommended dose for psoriasis is 300 mg by subcutaneous injection at Weeks 0, 1, 2, 3, and 4 followed by 300 mg every 4 weeks. Each 300 mg dose is given as 2 subcutaneous injections of 150 mg. For some patients, a dose of 150 mg may be acceptable.
- A study comparing retreatment-as-needed vs fixed-interval maintenance therapy showed that the standard fixed-interval dosing was superior in terms of efficacy [JAAD 2015;73;27].
- Secukinumab has been studied and used with methotrexate.
- If you stop Cosentyx after achieving a full response, there is on average a loss of 50% benefit over 28 weeks.
- Four year studies show sustained benefit and no increased incidence of side effects.
Concern with infection as with other TNF agents is noted. Candida infection has been noted at higher frequencies than placebo. Cases however seem to be mucocutaneous, mild and not systemic. Patients should be monitored for any signs of tuberculosis. New onset or exacerbation of IBD has been noted. Patients with Crohn's disease may want to avoid Cosentyx as patients with CD treated with secukinumab tended to have greater disease activity and increased adverse events.
Secukinumab has been reported to induce a psoriasiform eruption of the fingertips and nails. A 61-year-old woman with psoriasis cleared after 2 months of secukinumab, but 1 month later, developed severe, disabling fingernail dystrophy and distal onychopathy. Stopping the secukinumab and starting ustekinumab and topical methotrexate cleared the eruption [JAMA Derm 20-17;153;1194]. Of note, secukinumab has been used successfully to treat acrodermatitis continua of Hallopeau [JAMA Derm 2017;153;336].
Pregnancy Category B
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