Real-World Strategies for Biologic Dose Escalation and Reduction in Psoriasis and Psoriatic Arthritis: A Systematic Review
Orsola Crespi, Isotta Giunipero di Corteranzo, Eleonora Bongiovanni, Umberto Santaniello, Michela Ortoncelli, Pietro Quaglino, Simone Ribero, Luca MastorinoBackground:
Biologic therapies have improved treatment of moderate-to-severe psoriasis and psoriatic arthritis. However, real-world dosing often deviates from standard protocols to address suboptimal responses, sustain long-term control, and manage safety or cost. Dose escalation (DE) and dose reduction (DR) strategies are widely used, but data on their frequency, rationale, and outcomes remain fragmented.
Objective:
To systematically review real-world evidence on DE and DR practices for biologic therapies in moderate-to-severe psoriasis and psoriatic arthritis, focusing on definitions, clinical criteria, and success rates.
Methods:
A systematic literature review was conducted using PubMed, Scopus, Embase, and the Cochrane Library from January 1, 2005, through December 31, 2024. Eligible studies included adults with moderate-to-severe plaque psoriasis or psoriatic arthritis receiving tumor necrosis factor inhibitors, interleukin-12 (IL-12)/IL-23 inhibitors, IL-17 inhibitors, or IL-23 inhibitors, with reported off-label dose modifications. Data on definitions, timing, clinical criteria, and outcomes were extracted and synthesized.
Results:
From 2623 records, 63 studies were included. Dose adjustments were defined using varied clinical or timing criteria. DE was most successful when applied moderately and promptly. DR was commonly implemented after stable remission and maintained disease control in 50% to 90% of patients. Adalimumab was the most frequently adjusted biologic. IL-17 and IL-23 inhibitors also showed flexibility. Inconsistent definitions and outcome reporting limited comparability across studies.
Conclusion:
Dose adjustments are common but inconsistently defined, highlighting the need for standardized definitions and clinical guidance.