Dual targeted therapy in a patient with psoriasis and ulcerative colitis

Dear Editor, Psoriasis is an immune-mediated inflammatory disease (IMID) with many comorbidities, including ulcerative colitis (UC). Although highly effective targeted therapies exist for psoriasis and UC, treatment responses may be suboptimal, and the use of dual targeted therapy (DTT) may be considered when multiple monotherapies fail. We present a patient who had psoriasis refractory to multiple biologics and subsequently developed UC–both diseases resolved after DTT. A 37-year-old man presented with multiple thick plaques on his scalp and forehead at the age of 22 and was diagnosed with psoriasis. At the age of 25, psoriatic arthritis was diagnosed. Due to disease progression, he had been treated with phototherapy, methotrexate, acitretin, and multiple biologics, including etanercept, adalimumab, ustekinumab, golimumab, and secukinumab sequentially without sustainable adequate control [Figure 1].Figure 1: Changes in psoriasis area and severity index and body surface area from weeks 0 to 341 after biologics treatment. PASI: Psoriasis area and severity index, BSA: Body surface area.At the age of 34, golimumab was switched to ixekizumab. Despite improvement in his psoriasis, he experienced frequent bowel movements with loose, bloody stool, and UC was diagnosed after colonoscopy and biopsy. Ixekizumab was then switched to subcutaneous ustekinumab. Mesalazine and budesonide were initially prescribed. However, due to inadequate control, tofacitinib was subsequently initiated, and subcutaneous ustekinumab was switched to intravenous ustekinumab. Under this combination, his UC and psoriasis were both well controlled, with the psoriasis area and severity index remaining below 5.8 and body surface area 2.31% [Figure 2].Figure 2: Changes in psoriasis area and severity index and body surface area from weeks 341 to 691 after biologics treatment. PASI: Psoriasis area and severity index, BSA: Body surface area.DISCUSSION The effectiveness and safety of biologics in the treatment of psoriasis have been observed in most patients. Biologics for psoriasis are always given as monotherapy in pivotal studies,[1,2] and in one real world data, use of two biologics was found in 0.07%.[3] However, in other IMIDs, such as psoriatic arthritis or rheumatoid arthritis, combinational therapy is more common.[4,5] Use of DTT in psoriasis may be due to inadequate responses to monotherapy, treatment of comorbidities or for the control of new onset adverse events. Psoriasis and UC are both IMIDs with some shared targeted therapies, but anti-interleukin 17 inhibitors such as ixekizumab are relatively contraindicated due to the potential risk of UC aggravation.[6] There are multiple therapeutic options for psoriasis, and this patient qualifies for National Health Insurance (NHI) coverage for three conditions: psoriasis, psoriatic arthritis, and UC. Given that the patient’s psoriasis was more severe than the arthritis, monotherapy was initially selected based on psoriasis condition and the available reimbursed targeted therapies at that time points. However, insurance coverage for psoriasis treatment is limited to 2 years, which also influenced the choice of treatments. Given that the NHI would not cover two costly medications simultaneously, and the NHI limits the duration of drug coverage for UC only for 1 year, whereas use in psoriatic arthritis remains unrestricted, the patient chose to continue tofacitinib under the indication of psoriatic arthritis and used self-pay intravenous ustekinumab due to cost consideration after shared decision making. Both medications are also indicated for UC treatment. This approach has resulted in stable disease control of his skin, joint, and gut symptoms to date. Our patient had experienced multiple biologic failures, either primary or secondary and his psoriasis was only well controlled after the DTT of intravenous ustekinumab and tofacitinib with a lasting effect for up to 2 years, to date. While DTT has been explored in refractory cases of either psoriasis or IBD separately,[7,8] there are limited reports on the use of DTT in patients with coexisting psoriasis and UC. The potential of DTT as a therapeutic strategy for managing recalcitrant IMIDs cases should be further studied. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Financial support and sponsorship Nil. Conflicts of interest Prof. Tsen-Fang Tsai, an editorial board member at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article. All authors declared no conflicts of interest in writing this paper.