Balancing Safety, Efficacy, and Patient Preference in Biologic Selection for Inflammatory Disease

In the modern management of psoriasis and psoriatic arthritis (PsA), clinicians face an expanding array of biologic and targeted therapies. Selecting the most appropriate treatment requires balancing efficacy, safety, and patient preferences while addressing disease domains and comorbidities.

In an interview with The American Journal of Managed Care^® (AJMC^®) that was conducted at the 2026 Maui Derm Annual Meeting, Philip Mease, MD, director of rheumatology and research, Providence Swedish Medical Center, and clinical professor, University of Washington, emphasized that shared decision-making and careful interpretation of clinical evidence are essential to aligning therapy with patient needs.

A key starting point in treatment selection is medication safety. Clinical trial safety signals—such as infection risk or malignancy—emerge from large patient populations and must be communicated clearly, according to Mease. Understanding safety profiles helps patients weigh risks alongside expected benefits. Some patients prioritize safety above all else and may favor therapies perceived to have a clean safety profile, such as IL-23 inhibitors.

“One thing that is very important is to talk to patients about the safety of a medication, which we learn from treating lots of patients in a clinical trial and observing for things like infection or malignancy and so forth,” said Mease.

However, treatment decisions often shift when disease manifestations differ. PsA is a heterogeneous condition involving peripheral joints, skin, nails, enthesitis, dactylitis, and axial disease. Domain-specific efficacy therefore matters. Therefore, clinicians should consider which disease domains are most burdensome and select therapies with demonstrated effectiveness in those areas, according to Mease.¹

For patients with significant axial or spinal involvement, tumor necrosis factor inhibitors and IL-17 inhibitors are frequently favored because of robust evidence supporting axial disease efficacy.¹ Although IL-23 inhibitors are highly effective for skin disease and peripheral arthritis, axial data remain limited, and ongoing studies may further clarify their role.

Safety findings should also be interpreted within the broader context of immune-mediated inflammatory disease management, where long-term registry and postmarketing data often refine risk estimates beyond initial trial signals.² Additionally, comparative safety assessments must consider background infection risk, comorbidities, and concomitant immunosuppressive therapy, all of which can influence observed adverse event rates.

Patient lifestyle and treatment logistics are equally influential.¹ Route and frequency of administration can affect adherence and satisfaction. Patients may prefer oral therapies, clinic-based infusions, or self-injected biologics depending on work schedules, travel demands, and comfort with self-administration. Individuals who travel frequently.

“They may end up saying, ‘Well, I’d like a medication that’s only given once every 2 or 3 months, like one of the IL‑23 inhibitors, or once a month like one of the IL‑17 inhibitors,’ which is more convenient for their lifestyle,” said Mease.

Lifestyle factors and comorbidities also influence therapy choice. Methotrexate, a historically common oral therapy, may be less suitable for patients who regularly consume alcohol because of hepatotoxicity risk. Similarly, comorbidities such as obesity, metabolic syndrome, inflammatory bowel disease, or uveitis may favor specific biologic classes.

Mease also stressed the importance of critically evaluating clinical trial data. Trial design factors—including sex distribution and body weight—can influence outcomes. For example, higher proportions of patients with obesity in one treatment arm may attenuate apparent efficacy. Observed sex-related differences in treatment response may also influence results.

Moreover, safety findings must be interpreted cautiously. Adverse events observed in trials are not always attributable to the investigational drug; background risk, comorbid conditions, and concomitant medications may contribute. Clinicians should avoid overattributing causality without careful assessment.

Cross-trial comparisons present additional challenges. Without head-to-head studies, indirect comparisons between therapies can be misleading due to differences in study populations and methodologies. Comparative effectiveness research is therefore highly valued to guide formulary decisions and managed care policy.

Ultimately, effective treatment selection integrates rigorous evaluation of evidence with individualized discussions of safety, efficacy, convenience, and patient values. By tailoring therapy to disease domains, comorbidities, and lifestyle considerations, clinicians can optimize outcomes while supporting patient-centered care.

References

1. Steinzor P, Mease PJ. Tailoring psoriasis, psoriatic arthritis treatment to the patient: Philip Mease, MD. AJMC. January 28, 2026. Accessed February 23, 2026. https://www.ajmc.com/view/tailoring-psoriasis-psoriatic-arthritis-treatment-to-the-patient-philip-mease-md

2. McInnes IB, Gravallese EM. Immune-mediated inflammatory disease therapeutics: past, present and future. Nat Rev Immunol. 2021;21(10):680-686. doi:10.1038/s41577-021-00603-1