Understanding Discontinuation and Biologic Sequencing in Psoriasis

Real-world discontinuation patterns in psoriasis differ markedly from those observed in clinical trials. In the controlled trial setting, discontinuations are predominantly driven by loss of efficacy or adverse events. In clinical practice, however, a substantial proportion of treatment stops are attributed to non-clinical "other" reasons—including insurance lapses, changes in coverage, reduced patient engagement, concern about medications based on information from non-clinical sources, and general treatment fatigue. These practical barriers underscore the importance of proactive patient education and support systems that extend well beyond the clinical encounter.

When patients do discontinue tildrakizumab, the majority transition to another biologic, most commonly within the IL-23 or IL-17 classes. This pattern speaks to how clinicians conceptualize biologic sequencing based on mechanism of action. The distinction between primary and secondary loss of efficacy is central to these decisions: patients who fail to respond initially are generally transitioned to a different class, while those who respond but lose efficacy over time may benefit from switching within the same class—a strategy supported by emerging real-world evidence.

The IL-23 class offers a practical advantage in sequencing due to its predictable and robust efficacy. If a patient achieves meaningful clearance on one IL-23 agent but eventually loses response, switching to another agent within the class is a reasonable approach before moving to an alternative mechanism. Dosing frequency also plays a role in drug selection, with IL-23 agents offering convenient every-8- or every-12-week schedules that are often preferred by patients over the more frequent dosing associated with IL-17 inhibitors. Together, these considerations shape a nuanced, patient-centered approach to biologic sequencing in psoriasis.

References

1. Lockshin B, Beeghly A, Blachley T, Eliot M, Barghout V, Mathew J, Ferro T, Prajapati VH. Real-world tildrakizumab persistence in the US by biologic experience and insurance coverage in the PPD CorEvitas Psoriasis Registry. Poster presented at: Winter Clinical Dermatology Conference; January 16-21, 2026; Maui, Hawaii.

2. Prajapati VH, Blachley T, Eliot M, et al. Regional differences in patient characteristics among US biologic initiators from the PPD CorEvitas Psoriasis Registry. Poster presented at: Winter Clinical Dermatology Conference; January 16-21, 2026; Maui, Hawaii.