A Multi-center RCT Clinical Trial on Personalized Precision Medicine for Patients With Psoriasis and Psoriatic Arthritis and Investigation on Cardiovascular Biomarkers

To prepare the PBMC (peripheral blood mononuclear cell) culture, 16 mL of peripheral blood is collected from each patient using sodium citrate tubes (Vacutainer CPT, BD Biosciences, Franklin Lakes, NJ, USA). PBMCs are isolated by centrifugation at 1800 × g for 20 minutes at room temperature with the brake turned off, resulting in the separation of plasma, PBMCs, gel plugs, and red blood cell (RBC) layers.

The isolated PBMCs are washed with phosphate-buffered saline (PBS) and then cultured in RPMI-1640 medium supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin at 37 °C in a 5% CO₂ incubator.

A total of 6 × 10⁵ cells/mL are seeded into 12-well plates and treated for 24 hours under the following conditions:

Control

Streptococcus pyogenes only

S. pyogenes + adalimumab (4 μg/mL)

S. pyogenes + golimumab (0.5 μg/mL)

S. pyogenes + certolizumab (20 μg/mL)

S. pyogenes + ustekinumab (0.25 μg/mL)

S. pyogenes + ixekizumab (3.5 μg/mL)

S. pyogenes + secukinumab (16.7 μg/mL or 34 μg/mL)

S. pyogenes + guselkumab (1.2 μg/mL)

S. pyogenes + risankizumab (2 μg/mL)

Culture supernatants are collected for subsequent cytokine measurement. The concentrations of biological agents used correspond to the trough serum concentrations at steady state as indicated in the pharmacokinetic sections of reference data. The two concentrations of secukinumab (16.7 μg/mL and 34 μg/mL) reflect the two common clinical doses of 150 mg and 300 mg per month, respectively.

Cytokine Analysis

Cytokine levels are measured in the collected supernatants using a protein multiplex immunoassay system (Bio-Plex Cytokine Array System, Bio-Rad Laboratories, Hercules, CA, USA). The following cytokines and chemokines are analyzed:

IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17A, IFN-γ, TNF-α, monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory proteins (MIP-1α and MIP-1β), platelet-derived growth factor-BB (PDGF-BB), and chemokine (CC motif) ligand 5 (RANTES).

Screening Method for Biologic Agents

RANTES Exclusion First, biologics that induce a RANTES level ≥1.5 times higher than that of S. pyogenes-only treatment are excluded.

Scoring System for Biologic Selection in Psoriasis

Remaining biologics are categorized into three grades based on biomarker levels:

IFN-γ

IL-17A

IFN-γ/IL-4

IFN-γ/IL-13

IL-17A/IL-4

IL-17A/IL-13

Grade 1 (Most appropriate): Lowest biomarker values

Grade 2 (Possibly appropriate): Intermediate values

Grade 3 (Not recommended): Highest values

Each grade is subdivided into a, b, and c groups:

Lower values within a grade are ranked as a, followed by b, then c

Scoring is as follows:

1. a = +3, 1b = +2, 1c = +1.5 2. a = +1, 2b = +0.5, 2c = 0 3. a = -0.5, 3b = -1, 3c = -1.5

The total score for each biologic is the sum of individual biomarker scores. Based on total scores:

High score = Most appropriate

Medium score = Possibly appropriate

Low score = Not recommended

Scoring for Psoriatic Arthritis (PsA)

For PsA, biologics are selected based on the lowest RANTES, MCP-1 and IFN-γ levels:

• BSA (body surface area) [Time frame: From enrollment to the end of treatment at 48 weeks]
• Pruritus score [Time frame: From enrollment to the end of treatment at 48 weeks]
• Swelling joint counts [Time frame: From enrollment to the end of treatment at 48 weeks]
• Tender joint counts [Time frame: From enrollment to the end of treatment at 48 weeks]
• Dermatology Life Quality Index (DLQI) [Time frame: From enrollment to the end of treatment at 48 weeks]