Drug survival of adalimumab, ustekinumab and secukinumab in patients with psoriasis: a prospective cohort study from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR)

Background Real-world biologic drug survival is an important proxy measure for effectiveness. Predictors of drug survival may help patients with psoriasis choose between biologic therapies. Objectives (i) To assess the relative drug survival of adalimumab, ustekinumab and secukinumab in patients with psoriasis. (ii) To investigate predictors of biologic drug survival. Methods A prospective cohort study was performed in the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR) between November 2007 and August 2019. We performed survival analysis and fitted a flexible parametric survival model for biologic discontinuation due to ineffectiveness. Results In total 9652 patients were included: 5543 starting on adalimumab (57 center dot 4%), 991 on secukinumab (10 center dot 3%) and 3118 on ustekinumab (32 center dot 3%). The overall drug survivals of adalimumab, secukinumab and ustekinumab in year 1 were 0 center dot 78 [95% confidence interval (CI) 0 center dot 77-0 center dot 79], 0 center dot 88 (95% CI 0 center dot 86-0 center dot 91) and 0 center dot 88 (95% CI 0 center dot 87-0 center dot 89), respectively. The adjusted hazard ratios (adjHRs) for discontinuation of adalimumab and secukinumab compared with ustekinumab were 2 center dot 11 (95% CI 1 center dot 76-2 center dot 54) and 0 center dot 67 (95% CI 0 center dot 40-1 center dot 11), respectively. The presence of psoriatic arthritis predicted for survival in the adalimumab and secukinumab cohorts (adjHR 0 center dot 67, 95% CI 0 center dot 51-0 center dot 88 and 0 center dot 70, 95% CI 0 center dot 40-1 center dot 24, respectively), but for discontinuation in the ustekinumab cohort (adjHR 1 center dot 42, 95% CI 1 center dot 12-1 center dot 81). Previous exposure to biologic therapies predicted for discontinuation in the ustekinumab and secukinumab cohorts (adjHR 1 center dot 54, 95% CI 1 center dot 26-1 center dot 89 and 1 center dot 49, 95% CI 0 center dot 91-2 center dot 45, respectively) and for survival in the adalimumab cohort (adjHR 0 center dot 71, 95% CI 0 center dot 55-0 center dot 92). Conclusions Secukinumab and ustekinumab have similar sustained drug survival, while adalimumab has a lower drug survival in patients with psoriasis. Psoriatic arthritis and previous biologic experience were predictors with differential effects between the biologic therapies. What is already known about this topic? There is conflicting evidence over the real-world drug survival of secukinumab in patients with psoriasis. Data from registries to date suggest that secukinumab has a lower drug survival than that reported from clinical trials. What does this study add? This study found that secukinumab and ustekinumab had similar sustained drug survival in the real world, while the drug survival of adalimumab was lower, suggesting that the real-world drug survival of secukinumab is higher than previously reported. We found that psoriatic arthritis and previous biologic experience had differential effects on drug discontinuation in the three biologic cohorts. These predictors may help patients and clinicians choose the most appropriate biologic therapy.