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Which Biologic To Try?
from Alex X.

Hello Ed and thank you so much for your wonderful web site.

I have had severe psoriasis for more than 20 years and psoriatic arthritis for under 10.  I have used PUVA phototherapy (successfully but did not want to continue because of the dangers) and MTX (also helpful but had to stop because of liver complications).  I might now have the opportunity to try Raptiva or Amevive and it seems that I have the option to choose one or the other.  But my readings have been somewhat confusing. 

My main priority is PA, so if one of them is better for that I would immediately select it.  The clinicals seem to be equivalent on the psoriasis part (also similar to Enbrel).  Somewhere I saw that Amevive is in a pilot study for Psoriatic Arthritis, but many  anecdotal reports for both medications complain about joint pains and even someone reported developing PA while on Amevive.

If there is no other information, my quick readings up to now seem to favor Raptiva:

  • Subcutaneous versus intramuscular

  • No requirement of blood test to monitor T-cells

  • More people enrolled in the clinicals

I understand of course that different people respond differently to medications, but on paper these three points make sense to me.  Are you aware of any additional PA-specific information?  Enbrel seems to be superior (and approved) in that respect, but I do not have that option.

Again, thanks a lot for the great service you are providing to a community in need of help.  -Alex X.  


Ed’s Response:  Thanks for writing, Alex.  It may really be unfortunate that neither Enbrel or Remicade are on your list of possible biologics, since both of these are supposed to help PA.  During the six months I was using Enbrel, I believe it helped my PA, but it did nothing for skin. 

But from what I'm hearing about the biologics at large, regardless of which one you try first, I would counsel you to be prepared to try more than one.  I always suggest people accept their doctor's advice if it is satisfactorily explained to them; however, when it comes to new medicine regimens, I suggest you and the administering doctor agree to goals (in terms of improvement) a time line (how long to keep trying) and exceptions (things that might cause you to stop early).  Then, if the first thing you try doesn't meet your goals, be prepared to try another.

I reviewed Genentech’s prescribing information about Raptiva (go here) and mostly concur with your “bullets.”  The Genentech literature says your doctor “may monitor platelet counts” during your course of Raptiva, which would involve blood tests.  I would imagine that if I were in your shoes (about to try Raptiva) my derm would most definitely call me in monthly for blood workups (because of my recent history of severely depressed immune system function).  In general, though the Genentech mention of this is the mildest of any of the biologics I’ve read about.

Please drop us a line and let us know what you end up trying and how it works out.  A “mid-stream” report would be most welcome. -Ed

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