Biologics Linked to Lower Infection Risk in Older Adults With Psoriatic Disease

Older adults with psoriatic disease may face a lower risk of serious infections when treated with biologics targeting interleukin (IL)-12, IL-23, or IL-17, according to a new study.¹ The study found that these biologics were associated with fewer hospitalizations for infections compared with other systemic treatments.

Biologics targeting interleukin (IL)-12, IL-23, or IL-17 reduced serious infections, while tofacitinib increased infection risk, according to one study. | Image credit: ajr_images - stock.adobe.com

The cohort study is published in JAMA Dermatology.

“To inform treatment decisions for older adults with psoriatic disease, among whom infectious adverse events are a major concern, estimates of the relative risk of infection associated with different systemic treatments are needed,” wrote the researchers of the study. “The objective of this study was to estimate the association of different systemic treatments for psoriasis and psoriatic arthritis with the rate of serious infection among older adults.”

Psoriasis treatments are often similar across all age groups, including topicals, phototherapy, traditional oral medications like methotrexate and cyclosporine, newer oral inhibitors such as apremilast and deucravacitinib, and biologic injectables.² Around 15% of older adults with psoriasis experience moderate to severe disease, often necessitating systemic therapies for effective management. However, some systemic treatments considered low-risk in younger patients may pose greater toxicity concerns for older individuals.

This study utilized linked population-based health administrative data from Ontario, Canada, spanning from 2002 to 2021, including individuals aged 66 years and older with psoriatic disease who were prescribed their first systemic medication between April 1, 2002, and December 31, 2020.¹ Systemic medications were categorized into 5 groups: methotrexate, other older systemic medications, anti-tumor necrosis factor (anti-TNF) biologics, other biologics targeting IL-12, IL-23, and IL-17, and tofacitinib. The primary outcome was the time to serious infection, defined as hospitalization for any infectious cause up to March 2021.

Among the 11,641 older adults with psoriatic disease who initiated systemic therapy, 53% were female, with a median (IQR) age of 71 (68-76) years. During a median follow-up period of 4.8 (2.3-8.4) years, 1967 serious infections were reported. The incidence rates of serious infections per 100 person-years were 2.7 for methotrexate, 2.5 for other older systemic medications, 2.2 for anti-TNF biologics, 1.4 for other biologics targeting IL-12, IL-23, or IL-17, and 8.9 for tofacitinib.

In the multivariable-adjusted analysis, methotrexate (relative rates [RR], 0.95; 95% CI, 0.85-1.07), other older systemic medications (RR, 0.92; 95% CI, 0.79-1.07), and anti-TNF biologics (RR, 0.87; 95% CI, 0.69-1.10) were not significantly associated with serious infection risk. However, other biologics were associated with a significantly lower infection risk (RR, 0.65; 95% CI, 0.48-0.88), while tofacitinib was linked to a significantly higher infection risk (RR, 2.89; 95% CI, 1.14-7.34).

However, the researchers acknowledged some limitations to the study. First, the cohort consisted of older adults with a higher comorbidity burden, a population often underrepresented in randomized clinical trials, which may have impacted accuracy. Second, the absence of race and ethnicity data in Ontario's health administrative records limited the analysis. The researchers noted that healthy user bias may also explain the protective effects observed with newer biologics. Lastly, since Ontario Drug Benefit (ODB) policies require older systemic medication use before biologics, direct comparisons between methotrexate and biologic users may not accurately reflect real-world clinical scenarios.

Despite these limitations, the researchers believe the study supports the use of biologics targeting IL-12, IL-23, and IL-17 to reduce the risk of serious infections in older patients with psoriatic disease.

“The results of this study, combined with the established efficacy of biologics for psoriasis,30 suggest that biologics targeting IL-12, IL-23, and IL-17 could be favored over other agents to treat older adults,” wrote the researchers.

References

1. Drucker AM, Sutradhar R, Ling V, et al. Systemic therapies for psoriatic disease and serious infections in older adults. JAMA Dermatol. Published online March 19, 2025. doi:10.1001/jamadermatol.2025.0144

2. Lebwohl M. Psoriasis in older patients: Key considerations and best practices for effective management. International Psoriasis Council. Published May 29, 2024. Accessed March 18, 2025. https://psoriasiscouncil.org/expert-insights/psoriasis-in-older-patients-effective-management/