Talking Through the Risks and Benefits With Our Patients

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In our cover story this issue, Dr Justin Ko, the director and chief of medical dermatology for Stanford Health Care, describes the safety and efficacy of Janus kinase (JAK) inhibitors for alopecia areata (AA) and how to present them to patients. Because these drugs are widely useful for immune diseases, such as atopic dermatitis, psoriasis and psoriatic arthritis, vitiligo, and AA, our experience and comfort with them will continue to grow. Dr Ko describes a wrinkle particular to JAK inhibitors: how to present information on the cardiovascular black box warning associated with these drugs.

The whole idea of “safe and effective” seems nebulous to me. Nothing is completely safe. A drug may be safe in the sense that its risks are much less than the risk of the continued disease. A drug may also be safe in the sense that it is less risky than alternative treatments. Had JAK inhibitors, which affect the immune system without off-target effects, been available in 1990 when the only systemic treatments for patients with psoriasis were largely systemic steroids, methotrexate, and cyclosporine, I would have thought they were extraordinarily safe. Since then, I have become anchored on the safety of biologics, so even small safety risks make a drug seem not so safe anymore.

Going into detail on where the black box warning came from, Dr Ko gives us fabulous information that should not be missed on how to present the information to patients. I have some additional thoughts. A systemic immune inhibitor may be associated with about the same 1 in 100 risk of serious infection that people who are not on a systemic therapy have. I would never tell a patient there is a 1 in 100 risk of serious infection; the patient hearing that would focus on the 1, imagining what it would be like to have a serious infection and being terrified of the treatment. Instead, I like to tell my patients that 99 out of 100 people do not get a serious infection. Then patients do not even think about the 1 who does; they think about being 1 of the 99 who doesn’t. This is so much more reassuring.

I think sharing a success anecdote is also a helpful way to reassure patients about the safety and efficacy of a new treatment. Consider telling patients, “I had another patient so much like you, their disease was so similar, and they did great on this drug. I think it is the right choice.” This little anecdote, with no useful data in it at all, may be one of the most powerful ways to reassure a patient of a drug’s safety and efficacy—perhaps powerful enough to overcome a black box warning.

As Dr Ko describes it, we must consider each patient’s specific characteristics when making treatment decisions. Making the right diagnosis and prescribing the right therapy is only a small part of getting patients well. Getting to know and understand the patient and their specific needs—and changing the course of their lives for the better—can be some of the most fun, stimulating, and enriching aspects of medical care.