A systematic review and meta-analysis published in JAMA Dermatology has provided compelling evidence that switching between different classes of biologic therapies for psoriasis is both effective and safe for most patients. The comprehensive analysis, led by Dr. Miao Zhang from the Department of Dermatology at Yueyang Hospital of Integrated Traditional Chinese and Western Medicine in Shanghai, examined data from 24 randomized clinical trials encompassing 12,661 patients.
Significant Improvements in Treatment Outcomes
The meta-analysis revealed substantial improvements in psoriasis severity measures following interclass biologic switching. Compared to baseline, patients who switched biologics demonstrated remarkable gains across multiple Psoriasis Area and Severity Index (PASI) endpoints, including PASI 90 (OR, 28.61; 95% CI, 12.89-63.47), PASI 75 (OR, 11.11; 95% CI, 5.95-20.75), and PASI 100 (OR, 18.76; 95% CI, 8.37-42.01).
The study also documented rapid therapeutic benefits, with PASI 90 responses improving significantly as early as week 4 post-switch (OR, 6.53; 95% CI, 2.58-16.51). The most pronounced benefits occurred when patients transitioned from anti-tumor necrosis factor-α (anti-TNF-α) or anti-IL-12/23p40 agents to anti-IL-23p19 agents.
"This systematic review and meta-analysis found that, based on the results of 24 RCTs, interclass biologic switching was effective and there were no safety differences for most patients," the researchers concluded. "Specifically, switching from anti-TNF-α agents to anti-IL-23p19 agents and from anti-IL-12/23p40 agents to anti-IL-23p19 agents led to significantly improved effectiveness."
Safety Profile Remains Favorable
The safety analysis revealed reassuring results for most adverse event categories. No statistically significant differences were observed between post-switch outcomes and baseline for serious adverse events (OR, 1.63; 95% CI, 0.72-3.69), severe adverse events (OR, 1.40; 95% CI, 0.61-3.26), or treatment-related adverse events (OR, 1.79; 95% CI, 0.41-7.88).
However, the analysis did identify a modest increase in infection risk when switching from anti-TNF-α agents. The highest infection rates were observed when transitioning from anti-TNF-α drugs to anti-IL-23p19 (0.62%), anti-IL-17A (0.54%), or anti-IL-12/23p40 (0.39%) agents.
Addressing Clinical Practice Concerns
The research was motivated by prevalent concerns in clinical practice regarding biologic switching, including potential immune reaction increases, heightened safety issues, and efficacy considerations. "There is no scientific rationale to support or refute these concerns," Zhang and coauthors noted, explaining their decision to conduct this comprehensive analysis.
The study methodology was rigorous, utilizing searches of Embase, PubMed, and the Cochrane Library databases from inception through January 25, 2025. The analysis focused on randomized clinical trials involving adult participants aged 18 years or older with plaque psoriasis who had undergone crossover or switching from one biologic drug to another, either within the same drug class or to an alternate class.
Clinical Implications and Future Directions
The findings suggest that with the growing range of biologic options targeting distinct immunologic pathways, switching between classes may represent a valuable and potentially superior approach to psoriasis management for certain individuals. This is particularly relevant given that biologic therapy costs more than doubled from 2007 to 2021, rising from $21,236 to $47,125 annually.
"The findings of our study confirmed that interclass biologic switching improves short-term effectiveness and stabilizes long-term effectiveness without compromising safety," the researchers wrote. "We found no significant differences in effectiveness or safety between patients who switched biologics and those who continued the same treatment."
Despite the encouraging results, the researchers acknowledged several limitations, including heterogeneity of clinical trial designs, relatively short trial periods, and variations in adverse event definitions. They emphasized the need for larger studies with extended follow-up periods to obtain more conclusive results and highlighted the importance of vigilance for infections when switching biologics.
