BG03 Biologics for psoriasis in the older patient: profiles, pitfalls and practicalities

Abstract Psoriasis occurs at any age but its appearance in the seventh or subsequent decades may at first seem to present additional challenges. Around 15% of older patients with psoriasis have moderate-to-severe involvement that requires systemic therapy. The use of this may be complicated by increased levels of comorbidity and polypharmacy in comparison with younger age groups. Matters are further compounded by a senescent immune system and logistical issues. Hence, as the prescription of conventional treatments such as methotrexate or ciclosporin can be frustrated by drug interactions or contraindications, the use of biologics could actually be the most appropriate therapeutic avenue to pursue. Some evidence indicates that expectations of older patients are more realistic in terms of response than are those of younger subsets. The question then is whether biologics are as effective, as well tolerated and as commonly prescribed in older people with psoriasis as in younger cohorts? Several authors have considered this. In a small study, Momose et al. found ustekinumab or adalimumab to be effective but noted an increased incidence of side-effects (Momose M, Asahina A, Hayashi M et al. Biologic treatments for elderly patients with psoriasis. J Dermatol 2017; 44: 1020–3). In a review, Sandhu et al. noted similar efficacy and incidence of side-effects between older and younger groups but found that complications tended to be more serious in the former (Sandhu VK, Ighani A, Fleming P, Lynde CW. Biologic treatment in elderly patients with psoriasis: a systematic review. J Cutan Med Surg 2020; 24: 174–86). Osuna et al. observed that frequency of use was proportional in people aged > 65 years, and that ‘drug survival’ – a vital statistic in this field – combining both efficacy and side-effect profile – was also similar [Osuna CG, García SR, Martín JC et al. Use of biological treatments in elderly patients with skin psoriasis in the real world. Life (Basel) 2021; 11: 1348]. However, the presence of psoriatic arthritis in the older group was more likely to have influenced use of the biologic. In conclusion, it is apparent that indications for the prescription of biologics in patients in their seventh decade or more should be the same as in younger cases, but in view of comorbidities and concurrent drug use, there needs to be extra vigilance for side-effects and other complications.