Commentary
Under Pressure
One of the most important elements of a psoriasis patient’s medical history is the medication list.
We are always conscious of the use of systemic medications in older patients, as they may have the potential for more toxicity. For dermatologists, use of systemic medications in psoriasis represents a large share of our total use. Theoretically, we are concerned that older patients may be more likely to develop serious infections and malignancies. Older psoriasis patients also represent a growing demographic, and they are underrepresented in clinical trials.
In an article published online on September 3, 2014, in the Journal of the European Academy of Dermatology and Venereology, Medina et al performed an analysis to evaluate the safety of systemic psoriasis therapy in patients older than 65 years compared to younger patients. Patients registered in Biobadaderm, a Spanish national registry of psoriasis patients treated with systemic therapy, were divided into 2 categories: elderly (≥65 years) and younger patients (<65 years). Rates of adverse events (AEs) were described by severity and type. The risks were compared in both groups, taking into account exposure to classic or biologic drugs using Cox regression.
In the overall study population, 175 (9.8%) of 1793 patients were elderly. The authors found that overall risk for AEs was not higher in elderly patients; the drug group–adjusted hazard ratio (HR) was 1.09 (95% confidence interval [CI], 0.93-1.3). However, serious AEs were more common in older patients, with a drug group–adjusted HR of 3.2 (95% CI, 2.0-5.1). Age-adjusted HR of all AEs was lower for patients exposed to biologics compared to classic drugs in the whole sample (HR, 0.7 [95% CI, 0.6-0.7]). Age did not seem to modify the effect of therapy (biologic vs classic) in the risk for AEs (likelihood ratio test for interaction: P=.12 for all AEs; P=.09 for serious AEs).
The authors concluded that serious AEs were more common in elderly patients. They argued, however, that these serious AEs might be related to other factors associated with this age group and not due to the treatment itself. Use of biologics was associated with lower risk for AEs in the whole group. There were no differences in this association between young and old. These results are reassuring, though uncontrolled confounding could not be excluded as an explanation for these findings. The power of the study to detect differences was low.
What’s the issue?
The results indicate that overall there is no increase in AEs in older patients. More data will need to be evaluated to see if the incidence of serious AEs is due to medication use or endogenous health factors. How do you approach the use of systemic medications in older patients?
