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. 2024 Sep 19;16(16-17):1005–1013. doi: 10.1080/1750743X.2024.2401308

Bimekizumab for the treatment of hidradenitis suppurativa

Rayad B Shams a,b,*, Christopher J Sayed b
PMCID: PMC11492705  PMID: 39297706

Abstract

Hidradenitis suppurativa (HS) is a painful, inflammatory dermatosis involving recurrent abscesses, nodules and tunnels in intertriginous regions. Biologics and other immunomodulators have significantly expanded the treatment options available for HS. Bimekizumab is a monoclonal antibody targeting both interleukin-17A and interleukin-17F, key mediators of inflammation, that is already approved for psoriasis, psoriatic arthritis and axial spondylarthritis. It is currently pending FDA review for HS treatment but has already received marketing authorization for this indication in Europe. This review aims to explore drug-specific characteristics of bimekizumab including its mechanism of action, pharmacokinetics and pharmacodynamics and the current state of the literature regarding its use in HS such as safety, efficacy and dosing, while highlighting its implications in clinical practice. Recent Phase II and III trial data demonstrating positive efficacy and safety profiles in the treatment of HS will also be detailed.

Keywords: : bimekizumab, biologics, hidradenitis suppurativa, hidradenitis suppurativa treatment, immunotherapy, inflammatory dermatoses, interleukin-17, pharmacokinetics

Plain Language Summary

What is this review about?

Hidradenitis suppurativa (HS) is a skin condition that commonly causes painful abscesses, nodules, tunnels and scars with a predilection for areas of skinfolds like the underarms, under the breast and genital area. Multiple treatment options exist but none completely cure the disease. Treatments that target specific signals involved in the human immune system response are currently being used and developed for HS. Bimekizumab is an antibody-based treatment being considered for HS. It targets interleukin-17A and interleukin-17F (IL-17A/F), which are both involved in the inflammation in HS and other inflammatory conditions like psoriasis. In this review, we discuss how it works, its safety and its usefulness for the treatment of HS.

What were the results?

The available data show that bimekizumab is effective at treating the symptoms of moderate to severe HS by reducing the number of skin lesions and preventing new ones from developing in more patients compared with no medications. Additionally, it reduces pain from HS and improves patient quality of life at a higher level than a placebo medication. Bimekizumab was also found to be safe with few serious side effects. Common non-serious side effects included infections, gastrointestinal symptoms and headaches.

What do the results mean for managing hidradenitis suppurativa?

Bimekizumab is a viable treatment option for HS and may be considered in patients with moderate to severe HS if they have failed other treatment options. However, further research and long-term safety research is needed to support these recommendations.

Plain language summary

Article highlights.

  • Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition involving recurrent abscesses, nodules and tunnels for which bimekizumab, an interleukin-17 (IL-17) antagonist, is a potential therapeutic candidate.

IL-17 & its role in hidradenitis suppurativa

  • IL-17 is thought to be a key mediator of inflammation in HS. While IL-17A is a strong inducer of inflammation, IL-17F is found greater quantities in relevant tissues and also meaningfully contributes to overall inflammation.

Methods

  • We performed a review of the current literature regarding the mechanism of action of bimekizumab, its pharmacokinetics and pharmacodynamics, safety, dosing and its efficacy in treating both HS and other dermatological conditions.

Pharmacodynamics & pharmacokinetics of bimekizumab

  • Median serum bimekizumab trough at week 2 after a loading dose for HS was reported to be lower than in other conditions like psoriasis and postulated to be due to hidradenitis suppurativa's higher inflammatory burden.

Efficacy

  • Bimekizumab had excellent efficacy compared with placebo and was found to be non-inferior or superior to other treatment options for other dermatological conditions such as psoriasis and psoriatic arthritis. For HS, data derived from available Phase II and III trials demonstrated a significant decrease in overall HS activity and patient quality of life in the bimekizumab group compared with currently approved treatments and placebo.

Safety & side effects profile

  • Serious adverse events were very rare in the bimekizumab trials for HS. However, most commonly reported side effects included GI symptoms, headaches and infection. Nevertheless, clinicians should be aware of other potential serious side effects of bimekizumab such as suicidal ideation and behavioral changes.

Bimekizumab dosing & administration

  • Current recommended dosing of bimekizumab for HS, supported by the clinical trials data, consists of a 640 mg loading dose followed by 320 mg every four or two weeks injected subcutaneously via pre-filled syringes.

Clinical implications of bimekizumab for HS

  • Although bimekizumab is not currently FDA-approved for HS, it recently received marketing authorization for HS in the European Union (EU). In the United States, off-label use may be considered for moderate to severe HS patients refractory to other treatment options.

Future perspectives

  • Given the unique dual IL-17 inhibition of bimekizumab, it has the potential to be a leading management option for HS although additional trials exploring long-term safety and efficacy are needed.

Strengths & limitations

  • Strengths of our article includes a thorough but focused reviewed of the current literature on bimekizumab's mechanism of action, safety, pharmacodynamics, Limitations include potentially missed articles, HS being an incompletely understood disease and the still-evolving nature of bimekizumab's safety and efficacy in treating HS.

Conclusion

  • Current data suggest bimekizumab is a safe and efficacious drug in treating HS with excellent potential to be a leading HS management option given its unique mechanism of action.

1. Introduction

Hidradenitis suppurativa (HS) is a persistent, inflammatory skin disease manifesting as recurrent, painful nodules, abscesses and tunnels commonly in intertriginous areas such as axillae, groin and buttocks [1]. Although the exact mechanism of HS has not been fully elucidated, it is hypothesized to be related to an overactive inflammatory response that may be partially triggered by follicular dysregulation and microbial dysbiosis [2]. HS severity is reported as Hurley Staging with stage I denoting the presence of single or multiple abscesses without scars or tunneling (sinus tracts), stage II describing the presence of a single or limited scars or tunnels, and stage III with extensive and/or interconnected tunneling and scars [3].

Onset of symptoms generally occurs during the second decade of life although a bimodal distribution with a second peak around the mid-40s has been proposed [4]. The true prevalence of HS is unclear with the best estimates ranging from 0.4% to 1.2% [5,6]. A pooled prevalence analysis of 39 studies by Sachdeva et al. found the highest prevalence among African Americans (1.3%), followed by Caucasians (0.75%) and “Other” race (0.17%) which includes Middle Eastern, Asian, Pacific Islander, Native American, Hawaiian and mixed-race patients [7]. It is important to note, however, that HS is often misdiagnosed, hence, true race-specific prevalences may be higher among certain races than others [8].

For people with HS, it is often a debilitating skin condition with a significant impact on psychological well-being, socioeconomic status and patient quality of life [9–12]. Pruritus, pain and malodor were all significantly associated with worse quality of life with worse dermatology life quality index (DLQI) scores reported by patients during months of active lesions, diabetics and younger patients [13,14]. HS also significantly impacted relationships with almost half of the surveyed patients reporting HS impacting their intimate relationships [15]. HS influences work performance and presenteeism with Yao et al. reporting a 27% decrease in work productivity and a 32.7% decrease in daily activities [16]. Finally, HS also has a high psychological burden with shame, coping mechanisms and pain being prevalent themes during patient interviews [17].

HS is thought to disproportionately arise in female patients at a 3:1 ratio suggesting a potential hormonal role in its pathogenesis, although this lacks significant evidence. It similarly disproportionately affects African American/Black people at a rate of 3:1. Additional major risk factors and comorbidities include obesity, metabolic syndrome and smoking [18,19]. Recent large scale genome wide association studies (GWAS) have also found evidence of a genetic component of HS. Two loci located in enhancer regulatory elements of the SOX9 and KLF5 genes, which are involved in follicular inflammation and epidermal differentiation, were associated with HS pathogenesis in an analysis by Sun et al. [20].

Multiple, albeit imperfect, treatment options exist for HS including topical and oral antimicrobials, intralesional and oral steroids, hormonal therapy such as spironolactone and oral contraceptives, laser hair removal and surgery [21,22]. However, their efficacy can be highly variable, limited to mild and moderate disease, or often in the context of an adjuvant therapy. Hence, over the last several years, immunomodulation with biologics targeting some of the inflammatory cytokines implicated in the pathogenesis of HS such as tumor necrosis factor-alpha (TNF-a) and IL-17 has presented a new frontier for treatment [23]. Among them, adalimumab (Humira), a TNF-a antagonist, was first to be approved for HS by the Food and Drug Administration in 2015 followed by secukinumab, an IL-17A antagonist, (Cosentyx) in 2023 [24,25].

Bimekizumab (Bimzelx®) is unique compared with other FDA-approved IL-17 antagonists that target either IL-17A or the IL-17 receptor because it is a bispecific antibody targeting both IL-17A and IL-17F [26]. In the US, it is currently only FDA-approved for the treatment of psoriasis, though applications for the treatment of psoriatic arthritis and HS are under review [27]. In Europe, it is currently approved for the treatment of HS, moderate to severe plaque psoriasis, psoriatic arthritis and axial spondylarthritis by the European Medicines Agency and has recently published successful Phase III trial data for HS [28,29]. In this review, we will explore the current state of the literature for bimekizumab including pharmacokinetics, safety and efficacy and clinical results with a specific focus on HS.

2. IL-17 & its role in hidradenitis suppurativa

IL-17 is a T-cell-derived proinflammatory family of cytokines capable of inducing cytokine and chemokine release from a variety of cells driving inflammation [30]. IL-17A, a chemokine of the TH17 T-helper cell subset has long been thought to be the signature molecule involved in the pathogenesis of various autoimmune and inflammatory disorders including numerous cutaneous dermatoses [31,32]. More recently, however, IL-17F, which shares homology and is often co-expressed with IL-17A by TH17 cells has garnered scientific interest as an additional target molecule [33]. Both IL-17A and IL-17F bind to the IL-17 receptor A and receptor C (IL-17RA and IL-17RC) as homo or heterodimers inducing immune cell chemotaxis and promoting inflammation [34]. Though IL-17A binds the IL-17 receptors with great affinity and is a stronger inducer of inflammatory cytokine and chemokine response, IL-17F is found in greater concentration in relevant tissues and leads to meaningful stimulation of inflammatory responses. IL-17A is also predominantly produced in T-cells, whereas IL-17F is produced in T-cells, myeloid cells and epithelial cells, suggesting it may have particular relevance to bacterial response mechanisms and inflammation in the skin that do not rely completely on signaling through T-cells [35,36].

In HS, genetic factors related to inflammation and follicular and epithelial stem cell dysregulation, environmental risk factors, microbial dysbiosis and mechanical stress lead to follicular rupture and release of multiple pathogen-associated and damage-associated molecular patterns (PAMP and DAMP). These in turn induce multiple inflammatory pathways, including the downstream IL-17 pathway and large-scale neutrophilic, mast cell, B-cell and T-cell infiltration [37–39]. TH17 cells and IL-17 signaling are thought to mediate a key role in the following feedback loop of inflammation and immune cell response as evidenced by multiple studies showing significant IL-17 gene expression and upregulation in HS skin [40–42]. Hence, IL-17A, IL-17F and the IL-17 receptors are potentially key therapeutic targets for the treatment of HS.

3. Methods

A narrative literature review utilizing PubMed/MEDLINE database was performed using the keyword “bimekizumab” with other keywords such as “safety”, “efficacy” and “mechanism of action” added as necessary. Searches on topics such as prevalence, risk factors, treatment and impact of HS were also completed using a similar methodology. Pertinent articles were manually reviewed for relevance and summarized in the manuscript as appropriate. The senior author provided dermatologist insights and clinical perspectives. This review was deemed exempt from an institutional ethics board review.

4. Pharmacodynamics & pharmacokinetics of bimekizumab

Bimekizumab is a humanized monoclonal IgG1 antibody that binds to both IL-17A and IL-17F homodimers and heterodimers. In vitro studies suggest a greater inhibitory response to the IL-17 signaling pathway when both IL-17A and IL-17F are suppressed compared with either cytokine alone [43,44].

Pharmacokinetic data for bimekizumab for HS patients are derived from a single Phase II, double-blind, placebo-controlled randomized clinical trial since additional studies are currently lacking (NCT03248531). After a single subcutaneous 640 mg loading dose, median serum bimekizumab trough concentration at Week 2 prior to another dose was reported to be 25.6 μg/ml. This is lower than the observed 39.4 μg/ml in studies of bimekizumab in psoriasis. The authors of the Phase II study proposed this may be due to a higher inflammatory burden in HS [45].

5. Efficacy

Bimekizumab has shown excellent efficacy for the treatment of other dermatological conditions such as plaque psoriasis and psoriatic arthritis. For plaque psoriasis, complete skin clearance after one bimekizumab injection was achieved for 43.3% of patients at week 4 and 75.4% of patients at week 16 respectively [46]. In a head-to-head trial of bimekizumab versus secukinumab, 61.7% of patients achieved a 100% reduction in Psoriasis Area and Severity Index (PASI) compared with 48.9% in the secukinumab group [47]. In another trial of adalimumab versus bimekizumab, 86.2% of patients on bimekizumab had a PASI 90 response compared with 47.2% in the adalimumab group. Similarly, in a randomized, placebo-controlled, double-blind study of bimekizumab for psoriatic arthritis (BE OPTIMAL), a significant portion of patients reached 50% improvement based on the American College of Rheumatology ARC50 response criteria compared with placebo (44% vs. 10%) with results comparable to adalimumab (46%) [48]. These findings suggest that bimekizumab may have similar results of equivalent or even greater efficacy than other currently approved treatments for HS.

Data regarding efficacy of bimekizumab for HS specifically is primarily from the key Phase II clinical trial by Glatt et al. and Phase III data from the BE HEARD I and BE HEARD II trials [29,45].

5.1. HS Phase II trial

In the Phase II, double-blind, placebo-controlled study, moderate to severe HS patients were randomized in a 2:1:1 ratio to either bimekizumab (640 mg loading dose at week 0 followed by 320 mg every 2 weeks) placebo or adalimumab (160 mg loading dose at week 0 followed by 80 mg at week 2 and 40 mg every week from weeks 4–10). The primary outcome was a minimum of 50% improvement in total abscess and nodule count (AN count) without increased abscess or draining tunnel count at week 12 (Hidradenitis suppurativa Clinical Response [HiSCR]). Secondary outcomes explored included a 75% and 90% reduction of modified HiSCR criteria, pain and Dermatology Life Quality Index (DLQI) scores [45].

For patients enrolled in this Phase II trial, compared with placebo, bimekizumab resulted in both improved HiSCR (57.3% vs. 26.1%) and International Hidradenitis suppurativa Severity Score (IHS4) scores at week 12. A higher percentage of patients also achieved the secondary outcomes at 12 weeks including HiSCR75 (46% vs 35% in adalimumab and 10% in placebo groups) and HiSCR90 (32 vs. 15% in adalimumab and 0% in placebo groups). Participants also reported greater improvements in global pain and life quality compared with placebo and adalimumab [45].

5.2. HS Phase III trial (BE HEARD I & II)

The Phase III trials, BE HEARD I (n = 778) and BE HEARD II (n = 726), evaluated two possible dosing regimens (320 mg every 2 weeks and every 4 weeks) versus placebo with the primary outcome being 50% improvement in HiSCR at 16 weeks. Patients were eligible if they were 18 years or older and had greater than 5 inflammatory lesions (abscesses and/or nodules) involving 2 or more distinct anatomic areas [29].

The primary end point of HiSCR50 was met for the 2-week dosing group for both BE HEARD I and BE HEARD II trials. For the 2-week group, clinically and statistically significant improvement in HiSCR50 was achieved for 48% vs. 29% in placebo for BE HEARD I and 52% vs. 32% for placebo in BE HEARD II. For the 4-week dosing group, the primary outcome was achieved for BE HEARD II (54 vs. 32% for placebo) but not for BE HEARD I (45 vs. 29%) (Table 1). Nevertheless, for both trials, the authors report a rapid and sustained response rate for most patients treated with bimekizumab as early as week 4. HS patients also experienced statistically significant HiSCR75 improvement, a secondary end point for the study, for both dosing regimens in BE HEARD II and the two-week dosing regimen in BE HEARD I (Table 1). Patients also reported improved DLQI scores and sustained response at 48 weeks [29].

Table 1.

Primary and secondary end point data for Bimekizumab for hidradenitis suppurativa from Phase III (BE HEARD I and II) trials.

End point of Interest BE HEARD I BE HEARD II
320 mg Q2W/Q2W (n = 143) 320 mg Q2W/Q4W (n = 146) 320 mg Q4W/Q4W (n = 144) Placebo/320 mg Q2W (n = 72) 320 mg Q2W/Q2W (n = 145) 320 mg Q2W/Q4W (n = 146) 320 mg Q4W/Q4W (n = 144) Placebo/320 mg Q2W (n = 74)
16-week HiSCR50a 59.8% 50.4% 53.5% 34.0% 56.1% 61.1% 58.5% 32.3%
16-week HiSCR75a 39.9% 37.4% 31.4% 18.3% 38.8% 40.5% 36.4% 15.7%
16-week HiSCR90a 21.9% 20.6% 20.1% 11.3% 19.9% 23.2% 21.0% 5.8%
16-week HiSCR100a 14.6% 17.2% 15.0% 7.0% 16.6% 16.1% 16.5% 4.3%
48-week HiSCR50a 60.6% 61.4% 52.7% 45.3% 60.6% 63.8% 63.2% 67.6%
48-week HiSCR75a 47.6% 44.7% 40.5% 39.6% 47.3% 59.8% 53.9% 47.3%
48-week HiSCR90a 29.2% 29.6% 25.3% 26.1% 31.8% 35.9% 36.7% 39.8%
48-week HiSCR100a 22.4% 22.9% 20.2% 17.8% 24.9% 24.3% 26.9% 34.1%
Mean change in DLQI from baseline at 16 weeks (SE) -5.0 (0.4) -5.5 (0.6) -2.7 (0.9) -3.2 (0.6) -4.7 (0.5) -3.2 (0.6)
HS Symptoms Daily Diary Worse Skin Pain response at 16 weeksa,b 36.7% 25.3% 16.1% 36.7% 32.9% 11.1%
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This table highlights the efficacy data from the two major Phase III trials (BE HEARD I and II) of bimekizumab for Hidradenitis suppurativa. Percentage of patients improving on bimekizumab (measured by HiSCR scores) are presented for two dosing regimens at 16- and 48-week intervals as well as patient-reported characteristics such as dermatological life quality index and HS symptoms daily diary worse skin pain response.

a

End points based on modified non-responder imputation where patients who received antibiotics listed as rescue HS medication or those who discontinued intervention due to adverse events or lack of efficacy were treated as non-responders in all future visits.

b

Response defined as improvement from baseline weekly worst pain score of 3 or higher of at least 3 points.

DLQI: Dermatology life quality index; SE: Standard error.

Taken together, these results demonstrate bimekizumab to be an effective, sustainable treatment option to improve HS severity, pain and patient life quality compared with placebo with non-inferiority and a trend toward higher response rates compared with adalimumab.

5.3. Other studies of bimekizumab for HS

Two smaller studies provide additional data regarding the efficacy of bimekizumab for HS. Real-world observation data for bimekizumab for HS demonstrated a statistically significant improvement in patient activity and patient-reported outcomes in patients at 16 weeks [49]. In a separate small case series of four patients with concomitant HS and plaque psoriasis by Molinelli et al., bimekizumab at 320 mg loading dose at 0, 4, 8 and 12 weeks followed by 320 mg maintenance doses demonstrated clinically significant improvement in HS symptoms [50].

6. Safety & side effects profile

Bimekizumab was found to have an excellent safety profile in clinical trials for other dermatological conditions like plaque psoriasis [51]. Bimekizumab was also generally considered safe for use in HS patients with the rates of adverse events similar between Phase II, Phase III and bimekizumab trials for other conditions [29,45,47,48,52,53]. The most commonly reported side effects of bimekizumab in the HS trials were GI symptoms such as diarrhea, hypersensitivity reactions, headaches and infections. Oral candidiasis in particular was common, present in 7%, 9.5% and 12.8% of patients in the Phase II, Phase III BE HEARD I and BE HEARD II trials respectively. Notably, rates of oral candidiasis were higher in the Q2W dosing groups in both Phase III trials compared with Q4W dosing or adalimumab group suggesting a dose-dependent response to IL-17A/F inhibition and a stronger relationship with IL-17F than IL-17A alone [54]. However, most were reported to be mild and resolved with standard anti-fungal therapy, without requiring treatment discontinuation.

New incidence of inflammatory bowel disease (IBD), which has previously been reported to be associated with HS, was not seen in Phase II trials but was found in 7 patients in the Phase III trials predominantly after the 16-week period [55]. However, among those with prior IBD, no flares were reported. Hepatic enzyme elevations occurred in 2.8% of patients in the Phase III trials but no significant elevation (>5× upper limit or normal elevation) was attributed to bimekizumab [29].

Serious adverse events requiring hospitalization occurred for 2 patients (4%) treated with bimekizumab compared with 5% in the adalimumab group and 10% in the placebo group in the Phase II trial, namely one incidence of anemia and one episode of empyema. Rates of other serious adverse events of interest such as neutropenia, myocardial infarctions and malignancies were very low to absent in all Phase II and III trials. No deaths were reported in Phase II and one death due to cardiovascular disease presumed unrelated to treatment administration was reported in the Phase III trials.

Safety of bimekizumab can be further elucidated from its prior trials for other inflammatory and autoimmune conditions such as plaque psoriasis (BE RADIANT and BE BRIGHT), psoriatic arthritis (BE OPTIMAL and BE COMPLETE) and axial spondyloarthritis (BE MOBILE I and II) [48,52,56–58]. In those Phase III trials, the most common adverse events were nasopharyngitis, upper respiratory tract infection, oral candidiasis, headache and GI symptoms. Urinary tract infections were noted as adverse events in the plaque psoriasis and psoriatic arthritis trials but not the axial spondyloarthritis trials. No deaths attributed to bimekizumab-related adverse events were reported in any of the aforementioned trials.

During two clinical trials for bimekizumab (BE VIVID and BE READY), higher rates of suicidal ideation and behavior were reported for the bimekizumab group versus placebo prompting close monitoring [28,59]. Subsequent pooled analysis using the Columbia Suicide Severity Rating Scale (C-SSRS) suggested an increased relative risk for passive suicide ideation among patients treated with bimekizumab compared with placebo even without a prior history. Importantly, however, a causal relationship has not been established [60]. Nevertheless, it is recommended that prescribers carefully consider the risks and benefits of prescribing bimekizumab, especially in patients with a prior psychiatric history and seek patient and family cooperation in monitoring for new onset or worsening mood changes, depression and suicidal ideation or behavior.

Overall, bimekizumab appears to have a favorable safety profile for HS patients, although clinicians should counsel patients on common side effects such as infections such as oral candidiasis, headaches and GI symptoms. Clinicians should also discuss potentially serious adverse effects such as suicidal ideation or behavior, neutropenia and myocardial infarctions.

7. Bimekizumab dosage & administration

Current data regarding bimekizumab for HS in the aforementioned studies only investigates one dosing strength at two different frequencies. In both the Phase II and Phase III trials of bimekizumab for HS, patients received a loading dose of 640 mg at baseline followed by 320 mg either every two weeks or every four weeks. The doses were administered subcutaneously via pre-filled syringes, though auto-injectors are commercially available and have been evaluated in trials for other indications. The results suggest that 320 mg every 2 weeks after a loading dose may be superior in moderate to severe HS patients compared with every 4-week injections. However, 320 mg every 4 weeks may be considered if the clinician or patient prefers a stepwise increase in dosing or if the patient prefers fewer injections.

8. Clinical implications of bimekizumab for HS

Lack of FDA approval of bimekizumab for HS as of May 2024 limits the ability to consistently prescribe this emerging therapeutic option to people with HS in the United States. However, bimekizumab has already received marketing authorization within the European Union and long-term data from its use may provide further evidence of its importance as a management option for HS. For now, in the U.S., off-label use of bimekizumab may be considered for patients who have failed or had contraindications to approved treatments such as adalimumab and secukinumab at the approved doses. If bimekizumab is prescribed, clinicians should counsel patients regarding common potential side effects. Patients should be instructed to stop taking bimekizumab in cases of serious infection.

9. Future perspective

The current data regarding the efficacy and safety of bimekizumab for HS is promising. The future of bimekizumab for HS will depend largely on the safety and efficacy data from the Phase III clinical trial and subsequent ability to gain FDA approval. For patients with late-stage disease or those who have been unresponsive to prior treatment, bimekizumab may be a viable treatment option. The dual inhibition of IL-17A and F provides both short- and long-term disease improvement and control and hence may be superior in some ways to current alternative treatment options.

As bimekizumab becomes more widely used for HS, new, practical considerations will require attention and the generation of evidence. Adolescent patients were not included in the Phase II or III studies for bimekizumab, but the disease often develops in patients' teen years. It will be critical to generate safety, efficacy and pharmacokinetic data in adolescent patients by including them in future studies. Early intervention is critical to slowing disease progression so future study and regulatory approval for adolescent patients should be a major priority.

Another common scenario is the need for surgery as a concomitant treatment in those with incomplete responses to medication alone. Safety data for patients undergoing surgery for HS with TNF inhibitors such as adalimumab is robust and suggests that treatment does not need to be discontinued before or after surgery, but similar data for IL-17 antagonists, including bimekizumab, will be important so that unnecessary treatment interruptions are limited [61].

The high frequency of comorbidities in HS creates many unique clinical scenarios and opportunities to understand the impact of treatment on long-term health outcomes. Metabolic syndrome and cardiovascular mortality are significantly increased in people with HS compared with those without. Similar increases are well-characterized in patients with chronic inflammatory conditions such as psoriasis and rheumatoid arthritis and are alleviated with the use of systemic anti-inflammatory therapies such as methotrexate and inhibitors of TNF and IL-17 [62,63]. Whether drugs such as bimekizumab lead to similar reductions in patients with HS is a significant knowledge gap, and if such an effect is confirmed it would further improve its benefit/risk ratio in treating people with HS.

Another common comorbidity in HS is inflammatory bowel disease (IBD), and IL-17A antagonists are generally avoided in patients with IBD given the potential for causing increased disease activity [64]. Patients with IBD were not excluded from the Phase III bimekizumab trials for the treatment of HS, but few patients with both diseases were ultimately included. Significant rates in new cases or flaring for those with known disease were reported, but there is still hesitation to treat IBD patients with bimekizumab given the similarity in its mechanism of action to IL-17A antagonists. As real-world experiences are reported, it may become clear that the risks are lower with IL-17A/F antagonism and the benefits will outweigh the drawbacks even in this population.

Special populations such as pregnant women, those with Down syndrome, and patients with cancer history will also be important to study as each of these clinical scenarios is regularly encountered in clinical practice. Future studies may also explore other potential dosing and frequency of administration options to elucidate the best strategies for HS management for patients.

10. Strengths & limitations

Our review has multiple strengths including a thorough examination of the current state of the literature for bimekizumab use for conditions like HS with additional data regarding its efficacy for other conditions such as psoriasis and psoriatic arthritis. Additionally, we highlight promising results of bimekizumab for HS and discuss safety considerations, clinical implications and future perspectives. However, our review also had a few weaknesses. Despite the authors' best efforts, some articles not indexed in PubMed may have been missed. Additionally, because HS is incompletely understood and the current literature on bimekizumab for HS is still evolving, the data regarding safety and efficacy may change as future long-term studies are completed.

11. Conclusion

Bimekizumab is an emerging treatment option for hidradenitis suppurativa with clinically meaningful improvement in disease severity, pain scores and quality of life among patients with moderate to severe HS. It has a favorable safety profile in HS patients with few reported serious adverse effects. Future studies are needed to validate these efficacy and safety findings in the real-world setting, particularly in conjunction with other medical and surgical management strategies.

Author contributions

RB Shams was responsible for literature review and drafting of the manuscript. CJ Sayed was responsible for manuscript review and clinical expertise contributions. All authors contributed substantially to the writing of this manuscript.

Financial disclosure

RB Shams has no financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. The senior author CJ Sayed is an investigator for UCB Pharma and reports consultancy fees with UCB Pharma the maker of Bimekizumab.

Competing interests disclosure

RB Shams reports no financial disclosures or conflict of interests. CJ Sayed reports being an investigator for AbbVie, ChemoCentryx, Inicyte, InflaRx, Novartis and UCB Pharma; consultancy fees from AbbVie, Alumis, Astrazeneca, InflaRx, Sandoz, Incyte, Logical Images, Sonoma Biotherapeutics and UCB Pharma; speaker for AbbVie and Novartis. The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.

References

Papers of special note have been highlighted as: • of interest; •• of considerable interest

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