014 Combining secukinumab and apremilast to successfully treat refractory psoriatic skin and joint disease: a novel approach

Abstract

Background: Several therapies have been approved to treat PsA including relatively new additions of apremilast and secukinumab. No data exist on the safety or efficacy of apremilast in combination with IL-17 antagonists. We present a case of a highly refractory disease in a young male who was successfully treated with the dual therapy. Methods: Please see the results section. Results: A 23 year old male with childhood onset chronic plaque psoriasis presented to our unit with recalcitrant skin and joint disease. His prior treatments included ciclosporin (stopped due to severe mood changes), sulfasalazine (discontinued due to erythrodermic flare) and methotrexate upto 25mg weekly for two years with little benefit. Over subsequent years, he had adalimumab monotherapy for three years. Unfortunately, secondary failure led to the discontinuation. Ustekinumab promptly followed however had to be stopped after nine months due to primary inefficacy. Third biologic agent was infliximab for a year and again had to be terminated following inadequate response and a possible infusion reaction. All these therapies were prescribed at a different centre. At first visit to our unit, both his skin and joints disease were uncontrolled. His DLQI was 10 with PASI of 9.3. His PsARC assessment revealed 8T and 7S joints with both physician (PhGA) and patient (PtGA) global assessments of 4/5. His ESR was elevated at 39mm. EQ5D index value was -0.337 suggesting major impact on QOL. Apremilast was commenced at this stage. Twelve weeks later there was some improvement in his joints with 7T and 5S joints. PhGA and PtGA were 3/5. His ESR had dropped to 9mm. However his skin disease worsened with DLQI of 15 and PASI of 16.2. Secukinumab was added at 300mg monthly dose. At 16 weeks, there was substantial response with absolute clearance of the skin (PASI 0) and DLQI of 7. PsARC improvement was similar with 2T and 0S joints. ESR normalised to 2mm and both PhGA and PtGA were normal at 1/5. EQ5D also improved to 0.767. Nine months later, the disease remained well controlled with no adverse events. Conclusion: To our knowledge, this is the first case report of successful use of apremilast in combination with any IL-17 antagonist to treat PsA. Apremilast can be safely and effectively combined with secukinumab in patients with plaque psoriasis or psoriatic arthritis not responding adequately to these agents alone or standard advanced therapy. There are reports of combination therapy in people with psoriasis to good effect however most are limited to case series and retrospective cohort reviews. Certainly the data is limited and hitherto unreported in PsA. Our case underscores the efficacy of combination therapy of apremilast and secukinumab with no major adverse effects thus providing clinicians an effective strategy to manage challenging cases of PsA.