Switching within the interleukin-23 inhibitor class to tildrakizumab due to adverse events in two patients with severe chronic plaque psoriasis

Interleukin (IL)-23 p19 inhibitors are among the safest systemic therapies for moderate-to-severe plaque psoriasis, and randomised trials have not distinguished guselkumab, risankizumab, and tildrakizumab from one another on safety. Switching within or away from this class is therefore almost always undertaken for inadequate efficacy rather than tolerability. We describe two patients with severe chronic plaque psoriasis who were switched within the class to tildrakizumab because of recurrent adverse events despite complete skin clearance. A 76-year-old woman developed a reproducible viral-type illness after each risankizumab dose, and 62-year-old man experienced recurrent respiratory infections attributed to guselkumab. Both discontinued their prior agent while clear, subsequently relapsed, and then regained and maintained complete clearance on tildrakizumab for 34 and 30 months, respectively, without recurrence of the index adverse event. These cases suggest that intraclass switching to tildrakizumab can preserve disease control when a safety concern arises, without leaving the IL-23 class.