O04 Using biologic therapies as first-line systemic treatment for psoriasis: a cohort study following the target trial emulation framework from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR)

Abstract

In the UK, treatment pathways for moderate-to-severe psoriasis recommend initiating biologics only after failure or intolerance of conventional systemic therapies. Earlier biologic intervention may modify the disease course and improve both short- and long-term outcomes. The aim of this study was to compare treatment effectiveness and the risk of comorbidities between initiating biologic as the first systemic therapy and the standard of care, which starts with a nonbiologic systemic therapy, with optional subsequent switching to a biologic. This study followed a target trial emulation framework using data from September 2007 to December 2024 from the British Association of Dermatologists Biologics and Immunomodulators Register. We included patients with moderate-to-severe psoriasis [Psoriasis Area and Severity Index (PASI) ≥ 10] and no prior systemic therapy at enrolment. PASI and Dermatology Life Quality Index (DLQI) trajectories over 5 years were modelled using mixed-effects repeated-measures models. Complete skin clearance (PASI = 0) and the risk of chronic comorbidities (cardiovascular, hepatic, neoplastic, metabolic, mental health, musculoskeletal disorders and psoriatic arthritis) were estimated using marginal structural models. The study included 3702 patients: 3368 received standard of care and 334 initiated a biologic as their first systemic therapy. After 1 year, the predicted mean PASI [95% confidence interval (CI)] was 6.7 (6.3–7.1) for standard of care and 2.4 (2.0–2.9) for biologic initiators; DLQI values were 7.9 (7.4–8.4) and 4.0 (3.1–4.9), respectively. Over 5 years, the cumulative probability of achieving PASI 0 was 32.1% under standard of care vs. 58.6% with biologic initiation. Biologic initiation was associated with a higher likelihood of achieving PASI 0 (hazard ratio 2.85, 95% CI 2.34–3.47). The 5-year cumulative risk of developing new chronic comorbidities was 54.3% in the standard-of-care group and 47.5% in the biologic initiation group, suggesting a reduced risk of comorbidities (hazard ratio 0.72, 95% CI 0.58–0.89). In conclusion, initiating a biologic as the first systemic treatment for moderate-to-severe psoriasis was associated with better clinical outcomes and a lower risk of chronic comorbidities compared with standard of care.