Abstract Introduction and aims In the UK, biologics for moderate-to-severe psoriasis are typically initiated only after failure or intolerance of conventional systemic therapies. This stepwise approach may unnecessarily delay access to effective treatment, potentially increasing cumulative life-course impairment, comorbidity burden, and reducing quality of life. Methods This study used data from the British Association of Dermatologists Biologics and Immunomodulators Register from September 2007 to December 2024. We compared the effectiveness of initiating first-line systemic therapy with biologics from different classes vs. standard care, defined as starting with a nonbiologic systemic therapy with possible subsequent switching to a biologic. We included adults (≥ 18 years) with moderate-to-severe psoriasis baseline Psoriasis Area and Severity Index (PASI) ≥ 10 and no prior systemic therapy at registration. PASI trajectories over 5 years were modelled using mixed-effects repeated measures, adjusting for baseline and time-varying covariates. The probability of achieving complete skin clearance (PASI = 0) was estimated using marginal structural models with stabilized inverse probability weighting to address time-varying confounding. Results A total of 3702 patients were included: 3368 initiated standard of care; 167 started a tumour necrosis factor (TNF)-α inhibitor (i); 56 an interleukin (IL)-12/23i; 51 an IL-17i; and 60 an IL-23i. After 1 year, predicted mean PASI 95% confidence interval (CI) was 6.7 (95% CI 6.3–7.1) for standard care, 3.1 (95% CI 2.3–2.8) for TNF-αi, 2.1 (95% CI 1.2–2.9) for IL-12/23i, 2.6 (95% CI 0.8–4.3) for IL-17i, and 0.4 (95% CI 0.0–0.7) for IL-23i. Overall, 5-year cumulative PASI 0 rates were 32.1% for standard care, 47.8% for TNFαi, 48.2% for IL-12/23i, 67.0% for IL-17i, and 91.2% for IL-23i. Compared with standard care, all biologic classes showed significantly higher probability of achieving PASI 100: TNFαi hazard ratio (HR) 2.16 (95% CI 1.63–2.87), IL-12/23i HR 2.65 (95% CI 1.73–4.06), IL-17i HR 3.30 (95% CI 1.98–5.48), and IL-23i HR 7.45 (95% CI 5.25–10.58). Conclusions Our results suggest that initiating a biologic as the first systemic treatment for psoriasis improves treatment effectiveness compared with standard of care.
Phan et al. (Tue,) studied this question.