Ilumya (tildrakizumab) is a biologic that was FDA approved for the treatment of moderate-to-severe plaque psoriasis in adults in 2018. There are now at least eleven biologics that have been approved to treat psoriasis; however, few trials compare one to another. All are more effective than placebo (a treatment that has no active ingredient). Other biologics approved to treat plaque psoriasis include:

• adalimumab (Humira)
• brodalumab (Siliq)
• certolizumab pegol (Cimzia)
• etanercept (Enbrel)
• infliximab (Remicade)
• guselkumab (Tremfya)
• ixekizumab (Taltz)
• ustekinumab (Stelara)
• secukinumab (Cosentyx)
• risankizumab (Skyrizi).

These agents differ in the way that they work (some inhibit tumor necrosis factor [TNF], others block cytokines, such as interleukin 12 (IL-12), IL-23 or IL-17). They also differ in how frequently they need to be administered and there is some difference in cost.

According to guidelines issued by the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) in 2019 regarding the choice of biologics for plaque psoriasis:

• Biologics have a high benefit to risk profile and are an effective treatment choice for people with moderate-to-severe plaque psoriasis
• Of the 11 biologics currently available, there is no optimal or preferred biologic
• All 11 biologics have been ranked by the AAD and NPF as having grade A evidence for efficacy as monotherapy in the treatment of moderate to severe plaque-type psoriasis. Some biologics may be preferred over others for certain types of psoriatic disease (such as scalp psoriasis, nail psoriasis, and palmoplantar disease)
• Choice of biologic should be made taking into account a person’s medical and social factors
• In people who are overweight or obese, infliximab utilizes proportional-to-weight dosing and may be preferred in patients with higher body mass; Stelara also considers patient weight.
• IL-17 inhibitor treatment may reactivate or worsen IBD. TNF-α inhibitors and Stelara are approved treatments for patients with IBD and may be recommended in patients with comorbid psoriasis
• Avoid TNF-α inhibitors in people with class III and class IV congestive heart failure or multiple sclerosis
• Brodalumab has been associated with suicide, avoid in people with a history of suicidal ideation or recent suicidal behavior
• Stelara, Ilumya, and Skyrizi only require dosing every 12 weeks after administration of loading doses and maybe the best options for optimizing compliance
• Once a biologic has been decided upon, physicians should monitor how effective that biologic is and for the presence of side effects. A lack of response, loss of response, or severe side effects may warrant switching to a different biologic or the addition of other treatments.
• Biologics may be given as monotherapy or in addition to other therapies
• People who are prescribed biologics are at a higher risk for infection and important considerations need to made when immunizing and planning for surgery.

How does Ilumya compare with other IL-23 inhibitors?

The IL-23 monoclonal antibodies are the most recent generation of psoriasis biologics.

Ilumya was the second IL-23 inhibitor approved behind Johnson and Johnson’s Tremfya (guselkumab) which was approved in 2017. There is also a combined IL-12/23 inhibitor called Stelara (ustekinumab) that was first approved for plaque psoriasis in adults in 2009, and the approval then expanded to include adolescents (2017) and then children (2020). The most recent IL-23 inhibitor to be approved is Skyrizi (risankizumab), in 2019. Important differences to note include:

• After an initial loading dose, Tremfya is administered every 8 weeks, Ilumya, Stelara, and Skyrizi are administered every 12 weeks
• All are effective
• Skyrizi has a faster onset of action
• A comparative trial that compared Skyrizi to Stelara found Skyrizi to be more effective. At week 16, PASI 90 was achieved by 75% of Skyrizxi patients but only 42% of Stelara patients. By week 52, PASI90 was achieved by 82% of Skyrizi patients and only 44% of Stelara patients.
• Skyrizi also had a faster onset of action to Stelara, with 44% achieving PASI 90 by week four compared with only 19% with Stelara. Fewer adverse events were seen with Skyrizi compared with Stelara: however, the risk of serious infections was similar (but low). In people with a BMI >30, there was a slight loss of response with Skyrizi.
• Overall, Ilumya has a similar number of AEs when compared to Stelara and Tremfya.