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Presentation

Psoriasis, Obesity, and Treatment Options for Heavier Patients

Description

The speaker discusses how psoriasis treatment can be more challenging in patients with obesity, using a case of a 45-year-old man weighing about 200 kg with psoriasis, psoriatic arthritis, and multiple metabolic comorbidities. In the case, infliximab was initially considered because of weight-based dosing, but he was instead given high-dose cyclosporine briefly and then adalimumab, with only limited improvement. The main point is that TNF inhibitors, especially adalimumab, tend to work less well in heavier patients, while IL-17 and IL-23 agents are generally less weight-sensitive and may be better options; bimekizumab, ixekizumab, guselkumab, and risankizumab were highlighted, whereas secukinumab may perform less well at standard dosing in heavier patients. The talk also emphasizes treating the underlying obesity with GLP-1 medications such as semaglutide or tirzepatide, which can improve weight, joints, blood pressure, liver tests, and cardiovascular risk. Newer data suggest combining a GLP-1 with psoriasis biologics may further improve skin and joint outcomes, and while dose escalation can help in very heavy patients, insurance coverage is often a barrier.

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Conclusions

Obesity can significantly reduce the effectiveness of several psoriasis biologics, especially TNF inhibitors, making standard dosing suboptimal in heavier patients.
IL-17 and IL-23 agents appear to be less weight-sensitive and may perform better than TNF inhibitors in patients with obesity.
Escalating biologic dose can help some very heavy patients, but insurance coverage often limits this strategy.
Adding GLP-1 therapy such as semaglutide or tirzepatide can produce substantial weight loss and improve psoriasis-related comorbidities and disease control.
In the presented case, GLP-1 treatment led to major weight loss along with better joint symptoms, blood pressure, liver tests, and cardiovascular risk.
Emerging trial data suggest that combining ixekizumab with tirzepatide improves outcomes more than ixekizumab alone in both psoriatic arthritis and plaque psoriasis.
Overall, treatment of psoriasis in obese patients should consider weight-sensitive drug choice, possible dose optimization, and referral for obesity therapy when appropriate.

Paredes-Barbeito A et al. JAAD Reviews 6 p39.
Burshtein J et al. JAAD 92(4) 2025 p807-815.