Low compliance and polypharmacy as key negative predictors in highly effective anti‐psoriatic treatments

Biomarkers capable of predicting high‐cost anti‐psoriatic treatments are becoming increasingly important from a pharmacoeconomic perspective, as well as for practically promoting precision medicine in a daily setting. Nowadays, extensive clinical databases and omics provide big data to train powerful AI models and decode complex biological problems. The interpretation of these models remains critical and is often addressed by physician‐scientists who review AI‐based results, identifying missing variables that are necessary to apply the model on a daily basis.

In the meta‐analysis performed by Mao X and colleagues, they identified a higher comorbidity burden, obesity, special‐site involvement (e.g. genitals and nails) and older age as ‘independent predictors of poorer response to biologic therapy in psoriasis’. ¹ Interestingly, age at onset, baseline PASI and disease duration were not predictive of response to biologics, rejecting the hypothesis that disease severity may condition drug response. Conversely, all components of the ‘low responders’ group are linked to low compliance ² and polypharmacy (defined as taking >4 drugs). ³

Forty‐five percent of individuals aged over 65 years in Europe experience daily polypharmacy due to their concurrent comorbidities, compromising their mobility and triggering dysmetabolism (e.g. dyslipidaemia or diabetes). Furthermore, this cluster of patients also display lower compliance with therapies ³ and a greater likelihood of experiencing drug–drug interactions, adverse drug reactions and increased frailty. At the same time, several drugs are also linked to psoriasis exacerbation or even resistance to systemic anti‐psoriatic agents ⁴ through mechanisms different from those directly antagonized by biologics (e.g. beta‐blockers or lithium).

In the elderly population, dermatologists should focus more on strategies to increase patient compliance (e.g. recognizing and treating needle phobia) and decrease polypharmacy (e.g. deprescribing and chronomedicine). Drug delivery systems (pen vs. syringe vs. oral formulations) may also modulate long‐term compliance, especially if patients undergo frequent injections (i.e. reactive needle phobia). Injection retraining, utilization of adherence aids (e.g. apps or blister packs) or even matching administration times to daily routines may sustain motivation over the long term and boost compliance.

Deprescribing represents a paramount step in psoriatic patients with polypharmacy because it forces all specialists to reconsider the patient's overall health status, going beyond organ‐specific considerations. Remarkably, a chronomedical approach may also increase drug efficacy while minimizing side effects. In fact, any drug with a half‐life shorter than 15 h should be administered in accordance with chronotype and chronomedical principles due to its strong dosing‐time dependence. ⁵

In conclusion, patients with psoriasis over 65 years of age deserve a multidisciplinary evaluation before introducing immunosuppressive treatments into their routine to avoid polypharmacy and a drastic decline in long‐term compliance.

FUNDING INFORMATION

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CONFLICT OF INTEREST STATEMENT

The author declares no conflicts of interest.

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DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.