Tildrakizumab

Tildrakizumab
Monoclonal antibody
TypeWhole antibody
SourceHumanized (from mouse)
TargetIL23
Names
Trade namesIlumya, Ilumetri
Other namesTildrakizumab-asmn
Clinical data
Drug classMonoclonal antibody[1]
Main usesPlaque psoriasis[1]
Side effectsBack pain, headache, infection, nausea[2]
WHO AWaReUnlinkedWikibase error: ⧼unlinkedwikibase-error-statements-entity-not-set⧽
Pregnancy
category
  • AU: B1
  • US: N (Not classified yet)
    Routes of
    use    		Subcutaneous injection
    External links
    AHFS/Drugs.comMonograph
    MedlinePlusa618026
    Legal
    License data
    Legal status
    Chemical and physical data
    FormulaC6426H9918N1698O2000S46
    Molar mass144436.68 g·mol−1

    Tildrakizumab, sold under the brand name Ilumya among others, is a monoclonal antibody used to treat plaque psoriasis.[1] In the United Kingdom use is only recommended in severe disease that has not responded to other treatments.[2] It is given by injection under the skin.[3]

    Common side effects include back pain, headache, infection, and nausea.[2] Other side effects include angioedema and pain at the site of injection.[1] Use in the months before and during pregnancy is not recommended.[2] It works by blocking interleukin-23 (IL-23), a cytokine.[1]

    Tildrakizumab was approved for medical use in the United States and Europe in 2018.[3][1] In the United Kingdom it costs the NHS about £3,250 per dose as of 2021.[2] This amount in the United States costs about 15,300 USD.[4]

    Medical use

    It is used to treat moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy.[5][6]

    Dosage

    Tildrakizumab is administered via subcutaneous injection. It is available as a single-dose prefilled syringe containing 100 mg of tildrakizumab in 1 ml of solution.[5][6]

    It is given at a dose of 100 mg at weeks 0, and 4 and every 12 weeks thereafter.[5][6]

    In the European Union, a 200 mg dose is also approved for people with certain characteristics (high disease burden, body weight ≥ 90 kg) the 200 mg may provide greater efficacy.[6]

    Side effects

    Safety differentiates anti-IL-23p19 treatments from other biologic treatments. There is a theoretical risk of infection and malignancy with the use of any immunosuppressant, including biologics. However, compared with the inhibition of other inflammatory cytokines, IL-23 targeting may only minimally impair the ability to generate a proper immune response.[7][8]

    Tildrakizumab has proven to be a well-tolerated treatment in the long term.[9][8] The most common (≥ 1%) side effects associated with tildrakizumab treatment are upper respiratory infections, headache, gastroenteritis, nausea, diarrhoea, injection site pain, and back pain.[5][6] In the reSURFACE 1 and 2 clinical trials, the overall incidence of side effects was low and comparable to placebo.[10][8] Specifically, the incidence of severe infections, malignancies, and major adverse cardiovascular events was low and similar to that of placebo and etanercept treatment groups.[10]

    Mechanism of action

    Tildrakizumab is a humanized IgG1/k monoclonal antibody that selectively binds to the p19 subunit of the interleukin-23 (IL-23) cytokine and inhibits its interaction with the IL-23 receptor. IL-23 plays a critical role in modulating inflammatory and immune responses.[6]

    Recent research has found the IL-23/Th17 pathway to be crucial for the pathogenic mechanisms of psoriasis,[11] with IL-23 considered the “master cytokine” since it acts at the top of the inflammatory pathway, activating the proliferation of pathogenic Th17 cells and subsequent production of proinflammatory cytokines, including IL-17.[7]

    Structurally, IL-23 is a heterodimer with two subunits, p19 and p40. The p40 subunit is also shared with IL-12, a cytokine that is involved in the immune response. Treatments targeting the p40 subunit block both IL-23 and IL-12 and have been associated with an increased risk of infections.[8][7][11][12]

    Tildrakizumab binds only to the p19 subunit of IL-23. Through this specific blockage, tildrakizumab inhibits the release of proinflammatory cytokines and chemokines that mediate epidermal hyperplasia, keratinocyte immune activation, and tissue inflammation inherent in psoriasis.[6][12]

    History

    In March 2018, it was approved by the Food and Drug Administration for the treatment of moderate-to-severe plaque psoriasis as an injection for subcutaneous use in the United States.[13]

    In September 2018, it was approved by the European Commission for the treatment of adult patients with moderate-to-severe chronic plaque psoriasis who are candidates for systemic therapy.[14]

    The importance of IL-23 selective inhibition for the treatment of plaque psoriasis started to increase early after its identification in the year 2000, when it was found to be a crucial player in the pathogenesis of chronic immune diseases in general, and of psoriasis in particular. Based on that discovery, three monoclonal antibodies that selectively bind to IL-23p19 have been approved for the treatment of plaque psoriasis.[15]

    Originally developed by Schering-Plough, this drug became part of Merck's clinical program, following that company's acquisition of Schering-Plough in 2009.[16]

    In September 2014 Sun Pharmaceutical acquired worldwide rights to tildrakizumab for use in all human indications from Merck in exchange for an upfront payment of US$80 million. Upon product approval, Sun Pharmaceutical became responsible for regulatory activities, including subsequent submissions, pharmacovigilance, post approval studies, manufacturing and commercialization of the approved product.[17][18] In 2016, Sun Pharmaceutical signed a licensing agreement with the pharmaceutical company Almirall for marketing tildrakizumab in Europe.[18]

    As of March 2014, the drug was in phase III clinical trials for plaque psoriasis. The two trials enrolled nearly 2000 patients.[19][20]

    In 2016, tildrakizumab became the first IL-23p19 inhibitor to demonstrate positive results in Phase-3 clinical trials for the treatment of moderate-to-severe plaque psoriasis, further validating the importance of the role of IL-23 dependent pathways in psoriasis.[10] Later on, in 2019 the 3-year study results of continuous treatment with tildrakizumab were published. Given that psoriasis is a chronic disease that requires lifelong treatment, data on long-term maintenance of clinical responses and long-term safety are of special interest.[9]

    Research

    Tildrakizumab has been studied in around 1,800 patients in two double-blind, randomized and controlled Phase-3 trials, titled reSURFACE 1 and reSURFACE 2,[10] followed by a 4-year extension period.[10]

    In the reSURFACE trials, a significantly higher proportion of patients receiving tildrakizumab achieved PASI 75 response at week 12 and a PGA score of “clear” or “minimal”, with at least a 2-grade reduction from baseline at week 12, than those in the placebo group (p<0.0001). Response continued to increase up to week 28 and was maintained through week 52.[10][9] Tildrakizumab was also proven to have superior efficacy to etanercept, an effective anti-TNFα treatment for psoriasis, with a significantly higher proportion of patients achieving PASI 75 and PASI 90 at weeks 12 and 28.[10] After 3 years of continued treatment with tildrakizumab, response levels were well maintained in week 28 responders: approximately 68% of patients maintained PASI 90 response and 91.6%, 79.8% and 51.9% maintained an absolute PASI of <5, <3, and <1, respectively (observed-cases data).[9]

    References

    1. 1 2 3 4 5 6 "Tildrakizumab-asmn Monograph for Professionals". Drugs.com. Archived from the original on 29 September 2021. Retrieved 4 October 2021.
    2. 1 2 3 4 5 BNF (80 ed.). BMJ Group and the Pharmaceutical Press. September 2020 – March 2021. p. 1327. ISBN 978-0-85711-369-6.{{cite book}}: CS1 maint: date format (link)
    3. 1 2 "Ilumetri". Archived from the original on 25 June 2019. Retrieved 4 October 2021.
    4. ↑ "Ilumya Prices, Coupons & Patient Assistance Programs". Drugs.com. Archived from the original on 29 September 2021. Retrieved 4 October 2021.
    5. 1 2 3 4 ILUMYA™ Prescribing Information.
    6. 1 2 3 4 5 6 7 ILUMETRI® Summary of Product Characteristics. Almirall, July 2019.
    7. 1 2 3 Dolgin E (December 2016). "New anti-IL-23 drugs raise hopes for psoriasis plaque clearance". Nature Biotechnology. 34 (12): 1218–1219. doi:10.1038/nbt1216-1218. PMID 27926724. S2CID 205273437.
    8. 1 2 3 4 Pithadia DJ, Reynolds KA, Lee EB, Liao W, Wu JJ (2019). "Tildrakizumab in the treatment of psoriasis: latest evidence and place in therapy". Therapeutic Advances in Chronic Disease. 10: 2040622319865658. doi:10.1177/2040622319865658. PMC 6691657. PMID 31448070.
    9. 1 2 3 4 Reich K, Warren RB, Iversen L, Puig L, Pau-Charles I, Igarashi A, et al. (March 2020). "Long-term efficacy and safety of tildrakizumab for moderate-to-severe psoriasis: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2) through 148 weeks". The British Journal of Dermatology. 182 (3): 605–617. doi:10.1111/bjd.18232. PMC 7064936. PMID 31218661.
    10. 1 2 3 4 5 6 7 Reich K, Papp KA, Blauvelt A, Tyring SK, Sinclair R, Thaçi D, et al. (July 2017). "Tildrakizumab versus placebo or etanercept for chronic plaque psoriasis (reSURFACE 1 and reSURFACE 2): results from two randomised controlled, phase 3 trials". Lancet. 390 (10091): 276–288. doi:10.1016/S0140-6736(17)31279-5. PMID 28596043. S2CID 3428803.
    11. 1 2 Galluzzo M, D'adamio S, Bianchi L, Talamonti M (May 2017). "Tildrakizumab for treating psoriasis". Expert Opinion on Biological Therapy. 17 (5): 645–657. doi:10.1080/14712598.2017.1304537. PMID 28271735. S2CID 4041245.
    12. 1 2 Puig L (June 2017). "The role of IL 23 in the treatment of psoriasis". Expert Review of Clinical Immunology. 13 (6): 525–534. doi:10.1080/1744666X.2017.1292137. PMID 28165883. S2CID 3267755.
    13. ↑ "FDA approves Ilumya for plaque psoriasis". National Psoriasis Foundation. March 22, 2018. Archived from the original on April 23, 2020. Retrieved July 4, 2021.
    14. ↑ "Almirall: The European Commission approves Almirall's ILUMETRI® (tildrakizumab) for moderate-to-severe chronic plaque psoriasis". Archived from the original on 23 September 2018. Retrieved 23 September 2018.
    15. ↑ Fotiadou C, Lazaridou E, Sotiriou E, Ioannides D (2018). "Targeting IL-23 in psoriasis: current perspectives". Psoriasis: Targets and Therapy. 8: 1–5. doi:10.2147/PTT.S98893. PMC 5804022. PMID 29441315.
    16. ↑ "Merck, Schering-Plough set to complete merger [Press release]". Reuters. November 2009. Archived from the original on 2020-12-02. Retrieved 2021-07-04.
    17. ↑ "Sun Pharma and Merck & Co. Inc. Enter into Licensing Agreement for Tildrakizumab" (Press release). Merck. 17 September 2014. Archived from the original on 12 March 2015.
    18. 1 2 Bureau, BS B2B (28 July 2016). "Sun Pharma signs licensing pact with Spain's Almirall for tildrakizumab in Europe". Business Standard. BS B2B Bureau. Archived from the original on 2 September 2016. Retrieved 4 July 2021.
    19. ↑ Clinical trial number NCT01729754 for "A Study to Evaluate the Efficacy and Safety/Tolerability of Subcutaneous Tildrakizumab (SCH 900222/MK-3222) in Participants With Moderate-to-Severe Chronic Plaque Psoriasis Followed by a Long-term Extension Study (MK-3222-011)" at ClinicalTrials.gov
    20. ↑ Clinical trial number NCT01722331 for "A Study to Evaluate the Efficacy and Safety of Subcutaneous MK-3222, Followed by an Optional Long-Term Safety Extension Study, in Participants with Moderate-to-Severe Chronic Plaque Psoriasis (MK-3222-010)" at ClinicalTrials.gov
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