Secukinumab Initiation in Psoriasis

Patient Selection and Treatment Initiation

• The American Academy of Dermatology recommends secukinumab for adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy, with treatment initiated at 300 mg subcutaneously at weeks 0, 1, 2, 3, and 4, followed by 300 mg every 4 weeks 1
• Secukinumab is strongly recommended as monotherapy for moderate-to-severe nail involvement, palmoplantar plaque psoriasis, and psoriasis with psoriatic arthritis, with a strength A recommendation 1
• Patients with inadequate response to topical therapies alone are appropriate candidates for secukinumab 1

Pre-Treatment Considerations

• The American Academy of Dermatology recommends screening for active tuberculosis before initiating secukinumab therapy 2
• Screening for active infections or sepsis is also recommended, and initiation during active infection should be done in consultation with infectious disease specialists 2
• Untreated hepatitis B infection is a relative contraindication for secukinumab 2
• A history of inflammatory bowel disease should be assessed, as secukinumab may increase the risk of IBD events 3

Dosing and Administration

• The recommended dose of secukinumab is 300 mg subcutaneously, administered at week 0, week 1, week 2, week 3, and week 4, followed by 300 mg every 4 weeks 1
• Self-administration by subcutaneous injection is the standard route 1
• The 300 mg dose is more effective than 150 mg and should be prioritized 1

Safety and Efficacy

• At week 16, 79% of patients achieve PASI 90 with 300 mg secukinumab 1
• Response is maintained through 52 weeks and beyond with continued dosing 1
• Monitor for mucocutaneous candida infections, which occur at 1.9 per 100 patient-years but are typically mild and responsive to standard treatment 3
• Serious infections occur at low rates (0.015 per patient-year) but require treatment discontinuation until resolved 3

Combination Therapy

• Combination with topical corticosteroids or vitamin D analogues may be considered, though there is no published safety data on combinations 1
• No evidence supports combining secukinumab with other biologics, and such combinations carry unknown risks 4
• Secukinumab is recommended as monotherapy for all approved indications 1

Secukinumab Treatment Protocol for Moderate-to-Severe Plaque Psoriasis

Pre-Treatment Screening and Dosing Protocol

• The British Journal of Dermatology recommends screening for active tuberculosis and considering anti-tuberculosis therapy before starting secukinumab in patients with latent TB 5
• Administer secukinumab 300 mg subcutaneously at weeks 0, 1, 2, 3, and 4, followed by 300 mg every 4 weeks starting at week 8, as recommended by the British Journal of Dermatology 5
• Avoid injecting into areas of skin showing active psoriasis, as advised by the British Journal of Dermatology 5

Monitoring and Safety Considerations

• Most infections are non-serious, mild-to-moderate upper respiratory tract infections that do not require treatment discontinuation, according to the British Journal of Dermatology 5
• Serious infections occur at low rates, but require treatment discontinuation until resolved, as reported by the British Journal of Dermatology 5
• Monitor patients with serious infection closely and do not administer secukinumab until the infection resolves, as recommended by the British Journal of Dermatology 5
• Neutropenia may occur but is usually mild, transient, and reversible, according to the British Journal of Dermatology 5
• Watch for signs of inflammatory bowel disease; if new-onset or exacerbation occurs, discontinue secukinumab, as advised by the British Journal of Dermatology 5

Combination Therapy Considerations

• The Journal of the American Academy of Dermatology suggests that combination with high-potency topical corticosteroids with or without vitamin D analogues can augment efficacy 6
• Combination with topical corticosteroids or vitamin D analogues may be considered, though published safety data on combinations is limited, as reported by the Journal of the American Academy of Dermatology 6

Immunogenicity

• Less than 1% of patients develop antibodies to secukinumab up to 52 weeks of treatment, according to the British Journal of Dermatology 5

Vaccination Recommendations Before Starting Secukinumab for Psoriasis

Pre-Treatment Vaccination Strategy

• The American College of Rheumatology recommends that patients complete all indicated killed vaccines before starting secukinumab, and live attenuated vaccines must be administered at least 2-4 weeks before initiating therapy, though starting the biologic without delaying for killed vaccines is acceptable if disease severity warrants immediate treatment 7
• The British Association of Dermatologists considers anti-tuberculosis therapy before starting secukinumab in patients with latent TB 8

Live Attenuated Vaccines

• Live vaccines are absolutely contraindicated once secukinumab is started due to risk of severe or fatal infections from vaccine strain replication 9
• The National Health Service recommends live vaccines available in the U.K. include: BCG, measles, mumps, rubella, yellow fever, oral polio, and oral typhoid 9
• Delay starting secukinumab to administer live attenuated vaccines over starting the biologic and giving live vaccines concurrently 7

Killed Vaccines

• The American College of Rheumatology recommends starting the biologic and administering killed vaccines over delaying the start of biologic to administer killed vaccines 7
• Inactivated vaccines are safe to give to patients already receiving secukinumab 9

Specific Vaccine Recommendations

• The British Association of Dermatologists strongly recommends pneumococcal vaccine before starting any biologic therapy 9
• IL-17 inhibitors, including secukinumab, do not interfere with immune response to pneumococcal vaccination, unlike methotrexate which significantly impairs humoral responses 9, 10
• The American Academy of Dermatology recommends annual influenza vaccination 9
• IL-17 inhibitors and ustekinumab do not interfere with immune response to influenza vaccination 9, 10
• Patients with psoriatic disease should receive COVID-19 vaccines as soon as eligible 10
• IL-17 inhibitors do not significantly impair vaccine response based on data from other vaccines 10

Secukinumab Dosing and Long‑Term Management for Moderate‑to‑Severe Plaque Psoriasis

Recommended Dosing Regimen

• For adults with moderate‑to‑severe plaque psoriasis, administer secukinumab 300 mg subcutaneously at weeks 0, 1, 2, 3, and 4 (loading phase), then continue 300 mg every 4 weeks indefinitely as maintenance therapy. [AAD] 11

Loading Phase Details

• The loading phase consists of five consecutive weekly 300 mg injections; each dose may be given as a single 300 mg injection or as two 150 mg injections. [BAD] 12
• Each weekly injection should be given in a different anatomic site (upper arm, thigh, or any abdominal quadrant) and should avoid areas with active psoriasis lesions. [BAD] 12

Maintenance Phase and Duration

• Beginning at week 8, continue secukinumab 300 mg subcutaneously every 4 weeks; this schedule should be maintained without a predetermined stopping point. [AAD] 11
• The 300 mg dose is superior to 150 mg; approximately 79 % of patients achieve a PASI 90 response by week 16 with the 300 mg regimen. [AAD] 11
• Clinical response is sustained through at least 52 weeks and can be maintained for 2 years (demonstrated up to 5 years in trial data). [AAD] 11
• Discontinuation should be considered only if there is no clinical response after 16 weeks of therapy. [BAD] 12
• “As‑needed” dosing after the initial 12‑week period is markedly less effective than continuous every‑4‑week dosing. [AAD] 11

Dose Optimization and Non‑Recommended Strategies

• Do not extend the dosing interval to every 6 weeks even in patients who achieve early PASI 90 responses; this interval extension significantly reduces the likelihood of maintaining PASI 90. [AAD] 11
• Do not employ “as‑needed” or intermittent dosing after the loading phase; continuous every‑4‑week dosing is essential for durable efficacy. [AAD] 11
• Do not use the lower 150 mg dose when the 300 mg dose is appropriate; the higher dose provides markedly greater efficacy while maintaining a comparable safety profile. [AAD] 11

Pre‑Treatment Screening Requirements

• Perform tuberculosis screening for both active and latent infection; do not initiate secukinumab in patients with active TB. [BAD] 12
• In patients with latent TB, start appropriate anti‑tuberculosis therapy before beginning secukinumab. [BAD] 12
• Screen for other active infections or sepsis and defer therapy until resolved. [BAD] 12
• Conduct hepatitis B screening; untreated hepatitis B infection is a relative contraindication. [BAD] 12
• Review history of inflammatory bowel disease (IBD); secukinumab may exacerbate or trigger IBD, and therapy should be discontinued if new‑onset or worsening IBD occurs. [BAD] 12

Safety Monitoring and Adverse Event Rates

• Monitor for mucocutaneous candida infections, which occur at approximately 1.9 events per 100 patient‑years; these infections are usually mild and respond to standard antifungal treatment. [AAD] 11
• Serious infections are rare (≈0.015 events per patient‑year) but require temporary discontinuation of secukinumab until resolution. [AAD] 11
• New or worsening IBD should prompt immediate discontinuation of therapy. [BAD] 12
• Neutropenia observed during treatment is generally mild, transient, and reversible. [AAD] 11
• Development of neutralizing antibodies occurs in <1 % of patients and rarely impacts clinical efficacy. [AAD] 11