Efalizumab discontinuation: A practical strategy

Efalizumab is a recombinant, humanized IgG1 monoclonal antibody used in the treatment of plaque psoriasis. Efalizumab specifically targets T cells, leading to the subsequent inhibition of T-cell activation. The recent cases (three confirmed and one unconfirmed but suspected case) of the demyelinating disease progressive multifocal leukoencephalopathy (PML) have resulted in efalizumab being pulled from the market by European and Canadian regulatory agencies. Furthermore, manufacturer Genentech, Inc. has voluntarily withdrawn efalizumab from the United States market as of April 2009. In light of these events, this report is a practical guide to transitioning patients from efalizumab to alternative psoriasis therapies. The major consideration is the possibility for efalizumab-associated rebound of psoriasis. According to limited available literature and in the experience of the authors, the most effective agent for minimizing or preventing rebound is cyclosporine at the maximum dermatologic dose of 5 mg/kg per day.