Age and biologic survival in patients with ​moderate-to-severe psoriasis: a cohort study from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR)
Authors: Alabas Oras A , Mason Kayleigh J , Yiu Zenas Z N , Smith Catherine H , Warren Richard B , Grifﬁths Christopher E M ,   BADBIR study group, Barker Jonathan , Morrison Simon , Bewley Anthony , Evans Ian , Griffiths Christopher , Ahmed Shehnaz , Kirby Brian , Kleyn Elise , Laws Philip , Hampton Philip , Alabas Oras , McElhone Kathleen , Yiu Zenas , Mackenzie Teena , McPherson Tess , Murphy Ruth , Ormerod Anthony , Walton Shernaz , Reynolds Nick , Smith Catherine , Shipman Alexa , Ye Christina , Hughes Olivia , Warren Richard , Weller Richard , Gupta Girish , Zietemann Vera 
Published: January 2025

Abstract

Background
The current management of psoriasis does not differentiate between younger and older patients in selecting the safest and/or most effective biologic.

Objectives
To explore the effect of age at treatment initiation in response to biologics in patients with moderate-to-severe psoriasis in the UK and Eire.

Methods
Data from patients registered in the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR) from 2007 to 2024 on a first course of tumour necrosis factor (TNF), interleukin (IL)-12/IL-23, IL-17 and IL-23 inhibitors with at least 6 months’ follow-up were included. Patients aged ≥ 16 years at registration were organized into the following cohorts: 16–24 years, 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years and ≥ 75 years. The 45–54 years age group was used as the reference cohort. Biologic survival was defined as the time between treatment initiation to its discontinuation associated with ineffectiveness or the occurrence of adverse events (AEs). Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) was estimated using a flexible parametric model to compare discontinuing treatment between the age groups. Each model included exposure (biologic class), effect modifier (age groups), interaction terms, baseline demographics and clinical and disease severity covariates.

Results
In total, 14 294 patients were included and organized into the following age groups: 16–24 years, n = 847 (5.9%); 25–34 years, n = 2502 (17.5%); 35–44 years, n = 3575 (25.0%); 45–54 years, n = 3863 (27.0%); 55–64 years, n = 2338 (16.4%); 65–74 years, n = 954 (6.8%); and ≥ 75 years, n = 215 (1.5%). The interaction effects model showed that individuals aged 16–24 years were more likely to discontinue TNF inhibitors (TNFi) due to ineffectiveness than those in the reference cohort (aHR 1.30, 95% CI 1.10–1.55). For survival associated with AEs, individuals aged 55–64 years were at higher risk of discontinuing TNFi and IL-12/IL-23 inhibitors [IL-12i/IL-23i; aHR 1.33 (95% CI 1.13–1.56) and aHR 1.34 (95% CI 1.03–1.75), respectively]; those aged 65–74 years were more likely to discontinue TNFi, IL-12i/IL-23i and IL-17 inhibitors [aHR 1.89 (95% CI 1.54–2.31), aHR 2.00 (95% CI 1.47–2.73) and aHR 1.69 (95% CI 1.08–2.64), respectively], whereas individuals aged ≥ 75 years were at higher risk of discontinuing the four biologic classes.

Conclusions
Patients aged 16–24 years with psoriasis are more likely to stop TNFi due to ineffectiveness, whereas those aged ≥ 55 years are more likely to stop biologics due to AEs. These real-world findings provide important information for clinicians treating people with moderate-to-severe psoriasis across all age groups.