Treatment Preferences in Young Adults with Moderate to Severe Psoriasis: A Qualitative Study from the Nordic Countries.

INTRODUCTION: The purpose of this study is to explore treatment preferences and identify patient characteristics in young bio-naive adults with moderate to severe psoriasis in the Nordic countries (Norway, Finland, Sweden, and Denmark). METHODS: Patients were 18-45 years old and bio-naive but referred for biologic treatment of moderate to severe psoriasis. Patients were included at eight Nordic dermatology clinics. Patients with significant comorbidity or psoriatic arthritis were excluded. The Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were assessed along with basic patient information. A semistructured interview guide was used in individual qualitative interviews, asking patients about their treatment preferences and reasons, disease journey, and disease management. The interviews were analyzed using thematic content analysis. Twenty-four patients sufficed to reach saturation in this qualitative study. RESULTS: The patient sample characteristics represented a qualitative variation in age, sex, symptoms, duration of disease, and country. We included a total of 12 male and 12 female patients. The mean age was 34 years (range 18-45 years), the mean age at diagnosis was 20 years (range 6-34 years), the mean ± standard deviation (SD) time since diagnosis was 13 ± 8 years, PASI was 9.5 ± 4.7, and DLQI was 15.2 ± 6.4. Interviews suggested that both the burden of disease as well as the burden of treatment influenced patient preferences regarding treatment attributes, hence getting alleviation from symptoms did not alone influence patient preferences. Time, effort, and inconvenience related to psoriasis treatments also influenced patient preferences. CONCLUSIONS: This first in-depth, qualitative study in young bio-naive adults with psoriasis suggests that patient preferences are focusing not only on symptom relief but also on alleviating the burden of psoriasis treatment. Understanding the reasons for patient preferences and the perspectives of young adults is needed to guide individual shared decision-making in psoriasis management.

Not much research has been done on understanding the disease burden and treatment needs of young adults suffering from psoriasis. This is an interview study with young adults from Nordic countries suffering from moderate to severe psoriasis with an active lifestyle. The adult patients were all referred for biologic treatment of psoriasis but had not yet started treatment when they were interviewed. The aim was to explore treatment preferences in this group.The study showed that treatment goals depended upon both alleviation of symptoms and obtaining a low treatment burden. The most influential symptoms were scaling, itching, and visible plaques. The most important treatment burden features were efficacy, durability, speed of response, safety, and convenience. Understanding the reasons behind these different treatment preferences is essential to help shared-decision psoriasis management that matches individual needs.

Long-Term Health-Related Quality of Life in Patients with Plaque Psoriasis Treated with Certolizumab Pegol: Three-Year Results from Two Randomised Phase 3 Studies (CIMPASI-1 and CIMPASI-2).

INTRODUCTION: Certolizumab pegol (CZP) is an Fc-free, PEGylated, anti-tumour necrosis factor biologic. Safety and efficacy data for CZP over 3 years have been previously reported. We report 3-year quality of life (QoL) outcomes for patients treated with CZP, pooled from two phase 3 trials. METHODS: Adults with moderate-to-severe plaque psoriasis for ≥ 6 months were initially randomised 1:2:2 to double-blinded placebo every 2 weeks (Q2W), CZP 200 mg Q2W (loading dose of CZP 400 mg at weeks 0/2/4) or CZP 400 mg Q2W. All patients received open-label CZP (200 mg or 400 mg Q2W) from week 48. Dermatology Life Quality Index (DLQI), 36-Item Short Form Survey (SF-36), EuroQol 5-Dimensions 3-Level (EQ-5D-3L) and Work Productivity and Activity Impairment (WPAI) scores are reported as observed. RESULTS: At week 0, 100 patients were randomised to placebo, 186 to CZP 200 mg Q2W and 175 to CZP 400 mg Q2W. For CZP-randomised patients, 60.9% had a DLQI score of 0 or 1 by week 48. Both the physical and mental component scores of SF-36 also improved from baseline to week 48 (mean change from baseline: 4.4 and 5.4, respectively). The proportion of patients with a score of 1 in the EQ-5D-3L Pain/Discomfort dimension increased (week 0, 21.1%; week 48, 66.2%), and WPAI Presenteeism, Work Impairment, and Activity Impairment improved from baseline to week 48, with the strongest gains observed for Activity Impairment (week 0, 33.3% of time impaired; week 48, 6.7%). Across patient-reported outcomes, gains were sustained through week 144, with durable improvements observed regardless of sex, psoriatic arthritis status or prior exposure to biologics. CONCLUSION: CZP treatment was associated with sustained and tangible improvements in health-related QoL (DLQI and SF-36), health status (EQ-5D-3L) and functional impairment at work and in other daily activities (WPAI). TRIAL REGISTRATION: ClinicalTrials.gov NCT02326298 (CIMPASI-1) and NCT02326272 (CIMPASI-2).

Hexavalent vaccines: increasing options for policy-makers and providers. A review of the data supporting interchangeability (substitution with vaccines containing fewer antigens) and mixed schedules from the same manufacturer.

INTRODUCTION: Combination vaccines improve vaccine uptake and open the infant immunization space for additional vaccines. Hexavalent vaccines have been marketed since 2000. Infanrix hexa (combined diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type b conjugate vaccine, DTPa-HBV-IPV/Hib, GSK) is longest on the market, providing 16 years post-marketing experience. Each DTPa-HBV-IPV/Hib vaccine component is licensed alone and/or in smaller combination vaccines. Programmatic considerations sometimes require an interchange between vaccines due to unavailability, program change or mixed schedules (when the number of required antigens differs across scheduled primary vaccination visits). AREAS COVERED: Immunogenicity and safety data from 11 GSK-sponsored clinical trials support the interchangeability of DTPa-HBV-IPV/Hib within the same vaccines family, and use of DTPa-HBV-IPV/Hib in mixed primary vaccination schedules. EXPERT COMMENTARY: Data show acceptability of interchange of DTPa-HBV-IPV/Hib with other products within the same vaccines family and its use in mixed immunization schedules. This aligns with WHO recommendations that vaccines of the same family from the same manufacturer be used to complete the infant vaccination schedule. Interchangeability and suitability for use in mixed schedules is of interest for policy-makers/providers in the framework of vaccination recommendations as it provides flexibility. Given the complexity of larger combination vaccines, interchangeability or sequential use needs careful assessment.

A dynamic model of pneumococcal infection in the United States: implications for prevention through vaccination.

Universal infant vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7) has nearly eliminated PCV7-serotype invasive pneumococcal disease (IPD) in young U.S. children, but has been accompanied by increases in the incidence of serotype 19A IPD. Because antibiotic-non-susceptible 19A has increased more than antibiotic-susceptible 19A, antibiotic selection pressure could be contributing to this trend. We developed a dynamic compartmental transmission model of pneumococcus to better understand the causes of this rise and to estimate the impact of vaccines or changes in antibiotic use on future IPD incidence in the U.S. in <2 year-olds. The model predicted that with current practices, serotype 19A IPD incidence will plateau at about the 2007 level over the next few years. The model suggests that antibiotic usage played a major role in the rise in antibiotic-non-susceptible 19A IPD, with a lesser contribution from PCV7 vaccination. However, hypothetical large decreases in antibiotic use starting in 2008 are predicted to yield only gradual decreases in antibiotic-non-susceptible 19A IPD. On the other hand, vaccines with modest (20%) effectiveness against 19A (or 6A or PCV7-serotypes) carriage are predicted to substantially (by 80%) decrease the incidence of IPD caused by those serotypes within 10 years of implementation. Our findings highlight that vaccine effects on colonization are key to their overall benefits. In addition, serotype changes following vaccine introduction may have multifactorial origins, with antibiotic use an important factor for resistant strains such as 19A.

Long-lasting angiotensin type 1 receptor binding and protection by candesartan: comparison with other biphenyl-tetrazole sartans.

BACKGROUND: The ability of biphenyl-tetrazole angiotensin type 1 (AT1) receptor antagonists (BTsartans) to block angiotensin II (Ang II)-mediated responses has been extensively investigated in vascular tissues and, more recently, in cell lines expressing the human AT1-receptor. When pre-incubated, BTsartans acted surmountably (shifting the Ang II concentration-response curve to the right) or insurmountably (also decreasing the maximal response). It was shown that their insurmountable behaviour is due to the formation of tight, long-lasting complexes with the receptor. Partial insurmountable antagonism is due to the co-existence of tight and loose complexes. The proportion of insurmountable antagonism, the potency and the dissociation rate of the BTsartans decreases in the order: candesartan > EXP3174 (losartan's active metabolite) > valsartan > irbesartan >> losartan. OBJECTIVE: It is of interest to explore how tight AT1-receptor binding of BTsartans such as candesartan might contribute to their long-lasting clinical effect. METHODS: Computer-assisted simulations (COPASI program) were performed to follow the receptor-occupation and protection by different antagonists as a function of time. Free antagonist concentrations were allowed to decrease exponentially with time. RESULTS: The simulations suggest that slow dissociation does not tangibly prolong receptor occupancy if the free antagonist is eliminated at a slower pace (as is the case for BTsartans). Yet when surmountable and insurmountable antagonists occupy the same amount of receptors, insurmountable antagonists offer appreciably better protection against fluctuations in natural messenger concentration. CONCLUSION: Slow receptor dissociation and slow antagonist elimination are likely to act in synergy to produce long-lasting receptor protection.

Chronic corticosterone manipulations in mice affect brain cell proliferation rates, but only partly affect BDNF protein levels.

We investigated whether the effects of corticosterone (CORT) on brain cell proliferation are mediated via its detrimental effect on brain-derived neurotrophic factor (BDNF). Using a [3H]thymidine tracer study, it was demonstrated that the cell proliferation rate in the neurogenic hippocampus and subventricular zone was increased in placebo-treated adrenalectomized (ADX) mice with low plasma corticosterone levels when compared with chronically CORT-treated ADX animals (25mg or 100mg sustained-release pellet). The cell proliferation rate of SHAM animals was in between the ADX-placebo group and ADX CORT-treated groups. BDNF protein contents in the hippocampus and subventricular zone were not different between the SHAM group and ADX-placebo group, although BDNF contents were decreased in the chronically CORT-treated ADX animals. Thus, other factors besides BDNF are involved in mediating CORT-induced changes in cell proliferation. Further, CORT manipulations did not affect caspase-3-like activity in any of the brain regions investigated, suggesting that caspase-3 is not involved in possible CORT-induced cellular losses.

Gene expression profiles highlight adaptive brain mechanisms in corticotropin releasing factor overexpressing mice.

Corticotropin-releasing factor (CRF) plays an important role in mediating central and peripheral responses to stress. Alterations in CRF system activity have been linked to a number of psychiatric disorders, including anxiety and depression. Aim of this study was to elucidate homeostatic mechanisms induced by lifelong elevated CRF levels in the brain. We therefore profiled gene expression in several brain areas of transgenic mice overexpressing CRF (CRF-OE), a model for chronic stress. Several genes showed altered expression levels in CRF-OE mice when compared to their wild type littermates and were confirmed by quantitative PCR. Differences in gene expression profiles revealed the presence of previously unrecognized homeostatic mechanisms in CRF-OE animals. These included changes in glucocorticoid signaling, as exemplified by changes in 11beta-hydroxysteroid dehydrogenase type 1, FK506 binding protein 5 and serum/glucocorticoid kinase. Alterations in expression of genes involved in myelination (myelin, myelin-associated glycoprotein), cell proliferation and extracellular matrix formation (Edg2, Fgfr2, decorin, brevican) suggest changes in the dynamics of neurogenesis in CRF-OE. Pronounced changes in neurotensin (NT) receptors 1 and 2 mRNA were identified. Overall downregulation of NT receptors in CRF-OE animal was substantiated by receptor binding studies. Pronounced neurotensin receptor downregulation was observed for NT type 1 receptors in limbic brain areas, suggesting that NT could be implicated in some of the effects attributed to CRF overexpression. These data show that lifelong exposure to excessive CRF leads to adaptive changes in the brain which could play a role in some of the behavioral and physiological alterations seen in these animals.

Molecular characterization of the high-affinity [3H]neuropeptide Y-binding component from the venom of Conus anemone.

The venom of the marine snail Conus anemone contains the 'ANPY toxin' which binds neuropeptide Y (NPY) and related insect peptides with nanomolar affinity. This toxin has initially been proposed to be a major 18.5 kDa component of the venom. Here we demonstrate that the 18.5 kDa proteins of venom produce at least five different bands in native electrophoresis and that none of them binds [3H]NPY. Instead, the ANPY toxin migrates as a distinct band on native electrophoresis and is only present as a minor component in the venom. Its approximate molecular weight is 17.5 kDa and its [3H]NPY binding activity is extremely stable below 37 degrees C, even in the absence of protease inhibitors.

Distinct binding properties of the AT(1) receptor antagonist [(3)H]candesartan to intact cells and membrane preparations.

[(3)H]-2-Ethoxy-1-[(2'-(1H-tetrazol-5-yl)biphenyl-4-yl)methyl]-1H-benzimidazoline-7-carboxylic acid ([(3)H]candesartan), a non-peptide angiotensin II type 1 receptor (AT(1) receptor) antagonist bound with high affinity and specificity to intact adherent human AT(1) receptor transfected Chinese hamster ovary cells. The binding characteristics were preserved when cells were suspended, but the dissociation was 3-4-fold faster and the affinity 2-fold lower, while examining [(3)H]candesartan binding to cell membranes. These data suggested the role of the intracellular organisation of living CHO-hAT(1) cells in antagonist-AT(1) receptor interactions. Yet, a specific role of microtubule or actin filaments of the cytoskeleton, receptor phosphorylation by Protein Kinase C, membrane polarity, cytoplasmic components like ATP and the need of an intact cell membrane could be excluded. The potential effect of protease degradation or receptor oxidation during the membrane preparation was also unlikely. The dissociation rate and the equilibrium dissociation constant of [(3)H]candesartan increased with the temperature for both intact cells and membranes. Thermodynamic studies suggested that the bonds between candesartan and the hAT(1) receptor may be of different nature in intact CHO-hAT(1) cells and membranes thereof. Whereas the binding was almost completely enthalpy-driven on intact cells, there was a mixed contribution of both enthalpy and entropy on membranes.

Role of basic amino acids of the human angiotensin type 1 receptor in the binding of the non-peptide antagonist candesartan.

To explain the insurmountable/long-lasting binding of biphenyltetrazole-containing AT1-receptor antagonists such as candesartan, to the human angiotensin II type 1-receptor, a model is proposed in which the basic amino acids Lys199 and Arg 167 of the receptor interact respectively with the carboxylate and the tetrazole group of the antagonists. To validate this model, we have investigated the impact of substitution of Lys199 by Ala or Gln and of Arg167 by Ala on the binding properties of [3H]candesartan and on competition binding by candesartan, EXP3174, irbesartan, losartan, angiotensin II (Ang II) and [Sar1-Ile8]angiotensin. Our results indicate that both amino acids play an important role in the AT1-receptor ligand binding. Whereas the negative charge of Lys 199 is involved in an ionic bond with the end-standing carboxylate group of the peptide ligands, its polarity also contributes to the non-peptide antagonist binding. Substitution of Arg167 by Ala completely abolished [3H]Ang II, as well as [3H] candesartan, binding. Whereas these results are in line with the proposed model, it cannot be excluded that both amino acid residues are important for the structural integrity of the AT1-receptor with respect to its ligand binding properties.

Distinctions between non-peptide angiotensin II AT1-receptor antagonists.

A far-reaching understanding of the molecular action mechanism of AT1-receptor antagonists (AIIAs) was obtained by using CHO cells expressing transfected human AT 1-receptors. In this model, direct [3H]-antagonist binding and inhibition of agonist-induced responses (inositol phosphate accumulation) can be measured under identical experimental conditions. Whereas preincubation with a surmountable AIIA (losartan) causes parallel shifts of the angiotensin II (Ang II) concentration-response curve, insurmountable antagonists also cause partial (i.e., 30% for irbesartan, 50% for valsartan, 70% for EXP3174,) to almost complete (95% for candesartan) reductions of the maximal response. The main conclusions are that all investigated antagonists are competitive with respect to Ang II. They bind to a common or overlapping site on the receptor in a mutually exclusive way. Insurmountable inhibition is related to the slow dissociation rate of the antagonist-receptor complex (t 1/2 of 7 minutes for irbesartan, 17 minutes for valsartan, 30 minutes for EXP3174 and 120 minutes for candesartan). Antagonist-bound AT1-receptors can adopt a fast and a slow reversible state. This is responsible for the partial nature of the insurmountable inhibition. The long-lasting effect of candesartan, the active metabolite of candesartan cilexetil, in vascular smooth muscle contraction studies, as well as in in vivo experiments on rat and in clinical studies, is compatible with its slow dissociation from, and continuous recycling between AT1-receptors. This recycling, or `rebinding' takes place because of the very high affinity of candesartan for the AT1-receptor.