Lancet Reg Health Eur
Most psoriasis patients maintain results on lower biologic dose
Clinical takeaway: For patients with sustained low disease activity on an IL-17 or IL-23 inhibitor, a stepwise interval-prolongation strategy with close monitoring is a reasonable way to lower drug exposure and cost. Reescalation restored control in nearly all patients who experienced a flare.
IL-17 and IL-23 inhibitors have transformed moderate-to-severe psoriasis, but the newest agents cost roughly €17,000 (about $18,500) per patient per year and many patients sustain low disease activity that may not require the registered dose. Earlier work supported tapering of older biologics (adalimumab, etanercept, ustekinumab), but evidence for the newer classes has been thin and mostly limited to single drugs or non-randomized designs. This trial tested whether a disease-activity-guided, stepwise interval prolongation across seven IL-17 and IL-23 inhibitors could preserve control.
After 18 months, 73% of patients in the dose-reduction arm had successfully lowered their dose while keeping Psoriasis Area and Severity Index (PASI) scores at or below 5. Just over half were on 50% of the standard dose and about a quarter were on 67%. Persistent flares (PASI greater than 5 for at least three months) occurred in 4.0% of the reduction arm versus 1.6% of the usual-care arm, a between-group difference of 2.4%, meeting the prespecified 15% non-inferiority margin.
Success differed by drug class. Among IL-23 inhibitor users, 84% sustained dose reduction at 18 months, compared with 61% on IL-17 inhibitors. The trial was not powered for this comparison, but the gap is consistent with prior signals that IL-23 blockade may allow durable control at extended intervals. Short disease flares (a single PASI greater than 5) were more common with tapering, at 16% versus 6% with usual care, though they rarely escalated and were addressed at quarterly visits. Mean PASI and Dermatology Life Quality Index (DLQI) stayed low in both arms throughout follow-up.
The pragmatic, open-label trial randomized 244 adults at 19 hospitals in the Netherlands and Belgium (2:1 to reduction or usual care), stratified by biologic. Eligible patients had at least six months of PASI 5 or lower and DLQI 5 or lower on a registered dose of secukinumab, ixekizumab, bimekizumab, brodalumab, guselkumab, risankizumab, or tildrakizumab. Intervals were prolonged stepwise to 67% then 50% of standard if disease stayed controlled; PASI greater than 5 or DLQI greater than 10 triggered reescalation to the last effective dose.
No serious adverse events were attributed to dose reduction. Four cases of new-onset psoriatic arthritis occurred in the reduction arm and none in usual care, a difference the investigators flagged but noted could reflect the smaller usual-care group; worsening of preexisting psoriatic arthritis was actually more frequent under usual care.
The investigators argue the evidence is now sufficient to revise Dutch and Belgian guidelines to incorporate tapering as an option. The strategy depends on structured monitoring and willingness to reescalate promptly, but the cost case is substantial: the team estimates savings of up to €8,500 (about $9,250) per patient per year.
"Patients are afraid that their symptoms will return," said Elke de Jong, MD, dermatologist and professor of inflammatory skin diseases at Radboud University Medical Center. "That is why study participants were allowed to return to the standard dose at any time during the study if they wished, maintaining control."
Source: van den Reek JMPA. Lancet Reg Health Eur. 2026 Jun 1. Dose reduction of IL-17 and IL-23 inhibitors in psoriasis (BeNeBio study): an international, pragmatic, multicentre, randomised, controlled, non-inferiority trial