Painful Inflamed Skin Helped With Stronger Drug Dosing

Maureen Salamon

February 11, 2019

WROCLAW, Poland — Doubling the standard dose of adalimumab (Humira, AbbVie) for certain patients with hidradenitis suppurativa is an under-recognized but effective strategy that could change the treatment paradigm for this debilitating chronic inflammatory disease, a presentation of case studies suggests.

Many clinicians treating hidradenitis suppurativa consider increasing the dose of adalimumab, but "there are two obstacles," said Fernando Alfageme, MD, from Puerta de Hierro University Hospital in Majadahonda, Spain. "One is price, and the second is that it has never been done before and you may feel fearful about doing it yourself."

"Instead of changing to a not-so-proven treatment, why not intensify adalimumab?" he said, noting that the intensification of adalimumab therapy is already an established strategy in Crohn's disease.

"Maybe we should change our paradigm and think about a patient's inflammatory load rather than individual lesions," he told Medscape Medical News.

Alfageme presented three clinical cases, here at the Conference of the European Hidradenitis Suppurativa Foundation (EHSF) 2019, in which the weekly dose of adalimumab was doubled from 40 mg to 80 mg.

In the first case, the 80 mg dose was administered to a 21-year-old patient with severe hidradenitis suppurativa to hasten improvement after an intense flare.

In the second case, a 48-year-old woman with both Crohn's disease and hidradenitis suppurativa responded rapidly after she was mistakenly prescribed an 80 mg dose, but relapsed after the error was caught and she was returned to the 40 mg dose.

In the third case, a 24-year-old woman who could not lift her arms because of deep sinus tracts in her armpit areas related to hidradenitis suppurativa and was prescribed an 80 mg dose as her first biologic.

The dose intensification produced improvements with no adverse effects and without patients having to switch to an off-label biologic or add another treatment. In all three patients, clinical symptoms improved dramatically in 4 to 12 weeks, Alfageme reported.

Clinicians should try to keep to the minimum effective dose of adalimumab and reduce the intensification after 12 weeks if the disease is under control. "That way, if we see a bad flare, we can return to the intensified regimen," he explained.

EHSF President Christos Zouboulis, MD, from Dessau Medical Center in Germany, asked the nearly 200 audience members to submit case studies, with a particular emphasis on the duration of the intensified therapy.

Data Collection Through Case Studies

The data collection could lead to a published study, influence hidradenitis suppurativa treatment guidelines, "and help a lot of our colleagues," he explained.

Independent case series can provide very strong evidence of a treatment strategy's effectiveness, perhaps even more than organized research. "We don't get these experiences through studies, but from many years of working with patients," Zouboulis told Medscape Medical News.

Audience members chimed in immediately with their own experiences of intensified adalimumab therapy.

"I think adalimumab is under-dosed in psoriasis and HS," said Wayne Gulliver, MD, from Memorial University of Newfoundland in St. John's, Canada. "We know these drugs are very safe, so I agree 100% that we need to be updosing in appropriate cases."

A weekly adalimumab regimen of 80 mg for even 4 weeks can result in "incredible improvement in patients considered to be nonresponders," Zouboulis said. "We're obliged as doctors to maximize the activity of a drug."

Adalimumab is currently the only biologic drug approved for the treatment hidradenitis suppurativa by both the US Food and Drug Administration and the European Medicines Agency.

Alfageme and Zouboulis have disclosed no relevant financial relationships. Gulliver reports financial relationships with AbbVie, Amgen, Eli Lilly, Novartis, Pfizer, Actelion, Amgen, Arylide, Boehringer, Celgene, Cipher, Galderma, Janssen, Tribute, Astellas, LEO Pharma, and Regeneron.

Conference of the European Hidradenitis Suppurativa Foundation (EHSF) 2019: Abstract 038 OS08-01. Presented February 8, 2019.

Follow Medscape Dermatology on Twitter @MedscapeDerm and Maureen Salamon @maureensalamon


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