Antibiotic Exposure Linked to Increased Risk of Biologic Discontinuation in Psoriasis

Antibiotic use is linked with an increased risk of biologic drug discontinuation for psoriasis, new data suggest, though a causal link between antibiotics and diminished biologic durability remains undiscovered.1

These data were authored by investigators such as Raphaël Ouakrat, MD, from Université Paris-Est Créteil (UPEC) in France, all of whom set out to explore the impact of antibiotic utilization among patients with psoriasis on biologic treatment use. Prior to their study, the investigative team noted the potential of antibiotic use in patients with psoriasis to impact outcomes due to such drug interactions or immunologic impacts.

Additionally, the team highlighted the proposition suggesting gut dysbiosis may serve as a modifying factor for psoriasis therapy efficacy.2 Such prior data impacted their decision to pursue this subject.

“The aim of this study was to evaluate the association between oral antibiotic exposure and the persistence of biologic therapies in psoriasis,” Ouakrat and colleagues wrote.1

Study Design and Findings

Ouakrat and coauthors collected the necessary data from the French National Health Insurance database in this analysis. They also implemented a validated approach within the Système National des Données de Santé to identify patients living with psoriasis. In this process, the investigators selected a set of individuals who had been given at least 2 dispensations of topical vitamin D derivatives within a 2-year timeframe; in this method, there is a reported sensitivity of 84.5% and a specificity approaching 100%.

Among those included in this group, the investigative team would assess adults who subsequently were provided with at least a single biologic medication in the period between January 2012 - June 2022, following the second vitamin D dispensation. The index data would be the date of the first biologic prescription. Only those who were initiating biologic drugs who also had no biologic use in the preceding 12 months were deemed eligible by the team.

Ouakrat et al assessed the use of systemic antibiotics both at the point of baseline and throughout follow-up as a time-dependent variable. They categorized baseline exposure based on subjects' number of antibiotic dispensations in the 6 months before the study's index date and, during follow-up, this variable was continuously updated to reflect participants' level of antibiotic exposure within the previous half-year through the same categories.

The investigative team's main outcome was determined to be whether patients discontinued or switched their first biologic drug course. The team incorporated antibiotic exposure in the 6 months preceding initiation of biologic use and during follow-up into a weighted Cox marginal structural model for the purposes of generating adjusted hazard ratios. There were 36,129 individuals included as participants.

The team noted 42.0% of those involved in the analysis were women and 55.9% were men. These individuals had a mean age of 48.4 years. The investigators determined, at baseline, 25.9% of these subjects had been given an antibiotics prescription and 60.6% were provided with antibiotics at some point over the course of follow-up.1 Macrolides, β-lactams, and fluoroquinolones were noted to have been the antibiotic classes implemented by patients most frequently.

A link was found between exposure to antibiotics and an increase in participants' likelihood of stopping or switching biologic treatments, with a weighted hazard ratio of 1.12 (95% CI, 1.08–1.16).1 This association was shown by Ouakrat and coauthors to be more pronounced among those with multiple dispensations, whose weighted hazard ratio was 1.29 (95% CI, 1.24–1.35), suggesting a potential dose-response pattern.

Overall, the investigators noted a significant relationship was observed between antibiotic utilization and reduced persistence of biologic drugs in psoriasis. These data were described as consistent with the concept that antibiotics, potentially resulting from gut microbiome disruption, may negatively impact the durability of biologics. Nevertheless, the team noted residual confounding cannot be ruled out. They further pointed to the need for additional research to confirm such findings, suggesting a more favorable disease course than previously highlighted.

“While causality is unproven, minimizing unnecessary antibiotic exposure may support better treatment persistence,” the investigators concluded.1 “Further research is warranted to confirm these associations, clarify underlying mechanisms, and identify patient-related and treatment-related factors influencing biologic durability.”

References

1. Ouakrat R, Penso L, Sbidian E, et al. Antibiotic Use and the Persistence of Biologic Therapies in Patients With Psoriasis. JAMA Dermatol. Published online November 12, 2025. doi:10.1001/jamadermatol.2025.4427.

2. Gorelik Y, Freilich S, Gerassy-Vainberg S, et al; IIRN. Antibiotic use differentially affects the risk of anti-drug antibody formation during anti-TNFα therapy in inflammatory bowel disease patients: a report from the epi-IIRN. Gut. 2022;71(2):287-295. doi:10.1136/gutjnl-2021-325185.