The decision of which biologic treamtent to select for each patient can be a challenging one. Jennifer Cather, MD, of Modern Research Associates in Dallas, TX, provided a comprehensive look at the latest biologic psoriasis treatment options with attendees at the Winter Clinical Dermatology Conference Hawaii in January 2015. This article discusses her approach to treating individual patients with psoriasis.
Connect, Educate, Facilitate Change
At the meeting, she discussed the journey of psoriasis for patients and healthcare providers.
“There are 3 things that you can really do that will help patients. We can connect with them and this is important in trying to figure out how psoriasis affects them. We can educate them because we have a significant amount of data, but it’s very hard to implement it for these patients. We also need to facilitate change,” she said.
“If we can connect, educate and facilitate, we will really help patients,” said Dr. Cather, who works with a nurse practitioner to treat about 1,300 patients with moderate or severe psoriasis.
Many psoriasis treatment options exist (Figure 1). Dr. Cather’s presentation focused on biologic agents for moderate disease. Patients with psoriasis who are good candidates for biologic therapies include those with significant body surface affected; involvement of high impact areas, such as the face genitals, hands and feet; disease that impacts on quality of life and presence of psoriatic arthritis.
“For example, if you see a patient with palmoplantar psoriasis they can’t stand without being in pain. They can’t shake people’s hands. It’s very isolating,” she said.
The impact on quality of life can be significant. Dr. Cather suggests dermatologists ask several pointed questions, including: “How does this affect you? What do you want to do? What can’t you do? What is this disease preventing you from doing? She noted that some dermatologists might be surprised to hear the impact on the quality of life this disease has.
Understanding the Patient Experience
Numerous biologic agents are approved for psoriasis and psoriatic arthritis (Table 1) and several more are on the horizon. Currently, the main categories of biologic drugs for psoriasis are the tumor necrosis factor (TNF) antagonists (the effector cell cytokine antagonists), ustekinumab (Stelara, Janssen Biotech Inc.), which works on the regulatory cytokines, interleukin 12 (IL-12) and IL-23 and secukinumab (Cosentyx, Novartis Pharmaceuticals), which works on the regulatory cytokine IL-17.
Dr. Cather noted that using biologic treatment in practice can be complicated and the data results are not always reflected in the patient experience. All approved biologics have demonstrated efficacy and safety in randomized, controlled trials and open-label extensions for up to 3 years. However, differences in study design and handling of missing data complicate matters.
“There are meta-analyses showing that the probability of achieving a PASI [Psoriasis Area and Severity Index] 75 with a biologic is 80%.1 But I don’t think 80% of people are happy. And this goes to the fact that everybody is an individual. So if you can figure out a fingerprint of a patient’s psoriasis, how it affects them, you will get higher success rates and it won’t just be a number,” she explained.
It is important to evaluate why patients are considering biologics when they come into the clinic. Patients present for different reasons and at different ages.
“Our practice is a referral center, so the number one thing that comes up is a strong family history of psoriasis or word of mouth. If you have a psoriasis patient who has seen success, they are very interested in biologics,” she said.
Direct-to-consumer advertising is a big patient driver. She noted that patients also frequently say they have seen direct-to-consumer advertising, which can educate patients on the available options and also on the adverse effects that could possibly happen.
“Patients in their late teens and twenties also present at the clinic. This is a time in their lives when their lifestyle is opening up to include alcohol and sex and psoriasis can be an isolating disease that is progressive as a patient ages. It is my job to try to intervene and try to give people some of their life back,” she said.
Physicians, in general, like biologics because they are effective, and they are very safe (Figure 2). “The population in my clinic is two-thirds women. Pregnancies happen. Oftentimes they are not planned,” she said, noting that the safety data is positive. “There is some cardio-preventative data. I look at this treatment as something that will decrease inflammation and help them. Depression and fatigue also improve.”
Good Communication with Patients
Non-compliance is high with psoriasis patients. Dr. Cather recommended dermatologists tell patients before they start the biologic treatment (and again when they return for a follow-up with good results) that if they spontaneously stop their treatment, they will experience fatigue as a precursor to a flare. “They usually understand. That’s part of the education. You connect, you educate and you facilitate change. We would like to facilitate the change of not coming off medications,” she explained.
Patients achieve better results when dermatologists talk about the best way to implement biologic treatment. Discussing with the patient their previous medication history, such as which drugs were taken and what each experience was like, can help select the best option for patients. Dr. Cather suggested asking specific questions in addition to the names of the medications:
• What were you going through at the time of therapy?
• Did you have an infection?
• Did you have a break in therapy?
Behavior modification also can be used to help patients relieve symptoms. In addition, she often provides prescriptions or other recommendations to relieve symptoms (ie, gabapentin for itching or bleach baths for the head for patients who have a staph infection around the scalp or ear.)
“The best drug, the most effective drug, in the itching patient will not clear the disease,” she said.
The Typical Patient
The typical psoriasis patient is on 2 to 3 medications but has compliance issues. They may have additional health problems, including obesity, diabetes, cardiovascular disease or depression.2,3
In addition, lifestyle issues (such as drinking alcohol, smoking) and life issues (stress, economics, demands on their finances, time and competing priorities) may be present.
“I often tell patients there are things that you can control like alcohol and tobacco. I want you to try to get down to your ideal body weight,” she said.
In addition, many patients do not have a primary care provider (PCP) and the dermatologist can help them find one.
Complications of not treating psoriasis include an elevated systemic inflammatory burden and comorbidities, impact on quality of life (physical functioning and psychosocial impact) and economic impact (time lost from work, reduced productivity at work, not being promoted to leadership roles).
Dr. Cather noted that the biologic workup is crucial and should be thorough. This includes skin and joint exams, a full social history, family planning and lab work (Table 2). She noted that when clinical trials are done patient variables are fairly well-controlled. 
“We need to make sure our patients are healthy. For example, we want to make sure our young women have their Pap smears, that the age-appropriate screenings are done,” she said.
Clinical Experience
Dr. Cather provided an overview of her clinical experience with various biologic treatments.
TNF Inhibitors
Dr. Cather selects a TNF antagonist for patients with both skin and joint involvement; concomitant cardiovascular disease, Crohn’s disease and hidradenitis suppurativa.
“If they’re planning pregnancy soon I usually select etanercept (Enbrel, Amgen Inc.). Pediatric patients are usually on etanercept, and there’s a lot of concomitant data with hepatitis C with etanercept and adalimumab (Humira, AbbVie Inc.),” she said.
Ustekinumab
Dr. Cather noted she uses ustekinumab for significant skin involvement, demyelinating disease, obese patients, college students, patients who are afraid of needles, non-compliant patients and treatment-emergent psoriasis on TNF inhibitors.
“For heavier patients and those with major skin involvement, ustekinumab can be life changing. It also works well on patients with joint issues,” she said.
The dose regimen is given in 2 doses at the office, which appeals especially to young adults who want to disassociate their therapy from their life, she added. Non-compliant patients are more likely to stay on in-office therapy.
“Treatment-emergent psoriasis on TNFs can be seen with rheumatoid arthritis patients and Crohn’s patients. They develop a rash. Often they will be clutching their antifungal bottle when they come in. You can biopsy it, but I’m usually just switching them over to ustekinumab,” she said.
Some experts recommend abandoning TNF inhibitors, while others suggest treating through it. Consider the risk-benefit to decide if you should treat through, said Dr. Cather.
Psoriatic Arthritis
Dr. Cather pointed out that psoriatic arthritis provides a clinical challenge and her recent experience over the last few years has brought her to revise her previous thinking on the subject.
“For psoriatic arthritis, you better be in it to win it. The biggest change that I’ve had in the last 2 years is I believe many patients need to be on concomitant methotrexate with the biologics,” she said, noting that she previously recommended monotherapy, which is effective. “However, because this is a disease of a lifetime and adding methotrexate into the treatment is beneficial.”
Data now exists reflecting the worldwide experience with the TNF antagonists for multiple indications. “There is synergy with methotrexate, and methotrexate probably decreases the immunogenicity of all of the TNF antagonists, and probably should be used especially with your refractory patients or patients with psoriatic arthritis,” she added.
Women of Childbearing Potential
Overall, there are fewer treatment options for women with psoriasis, she noted. They can experience sexual impacts from their disease. Family planning should be discussed with female patients. Research shows that 50% of pregnancies were not planned.4
Dr. Cather encouraged dermatologists to have the women who become pregnant while on biologic treatment register with one of the pregnancy registries that exist for etanercept and adalimumab so more data will become available.
For more information, please call The Organization of Teratology Information Specialists (OTIS) at 877-311-8972 or visit www.otispregnancy.org.
Controlling Psoriasis
Today more treatment options are available than ever before. For optimal results, treatment should be individualized for each patient and dermatologists should understand the multiple options that are available because one agent will not work for all patients, according to Dr. Cather. Consultations with colleagues regarding difficult cases can be helpful.
It is important to manage comorbidities and promote overall health and well-being, especially if patients do not have a PCP. Skin cancer screenings are also necessary, especially for patients with a history of immunosuppressive therapies.
Psoriasis is a journey, and dermatologists are part of the journey.
“Try to connect with patients, educate them and facilitate change. It is a group effort. You need to involve the PCPs, too,” she concluded.
Disclosure: Dr. Cather is a consultant for AbbVie, Janssen, Leo Pharma and Novartis. She is on the speaker bureau for AbbVie and Janssen and conducts research for Allergan, Amgen, Celegene Galderma, Janssen, Merck, Novartis, Regeneron, Pfizer, Sandoz, Tolmar and Xenoport.
References
1. Langley RG, Reich K. The interpretation of long-term trials of biologic treatments for psoriasis: trial designs and the choices of statistical analyses affect ability to compare outcomes across trials. Br J Dermatol. 2013;169(6):1198-1206.
2. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006;55(5):829-835.
3. Davidovici BB, Sattar N, Prinz J, et al. Psoriasis and systemic inflammatory diseases: potential mechanistic links between skin disease and co-morbid conditions. J Invest Dermatol. 2010;130(7):1785-1796.
4. Stern RS, Nijsten T, Feldman SR, Margolis DJ, Rolstad T. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc. 2004;9(2):136-139.
The decision of which biologic treamtent to select for each patient can be a challenging one. Jennifer Cather, MD, of Modern Research Associates in Dallas, TX, provided a comprehensive look at the latest biologic psoriasis treatment options with attendees at the Winter Clinical Dermatology Conference Hawaii in January 2015. This article discusses her approach to treating individual patients with psoriasis.
Connect, Educate, Facilitate Change
At the meeting, she discussed the journey of psoriasis for patients and healthcare providers.
“There are 3 things that you can really do that will help patients. We can connect with them and this is important in trying to figure out how psoriasis affects them. We can educate them because we have a significant amount of data, but it’s very hard to implement it for these patients. We also need to facilitate change,” she said.
“If we can connect, educate and facilitate, we will really help patients,” said Dr. Cather, who works with a nurse practitioner to treat about 1,300 patients with moderate or severe psoriasis.
Many psoriasis treatment options exist (Figure 1). Dr. Cather’s presentation focused on biologic agents for moderate disease. Patients with psoriasis who are good candidates for biologic therapies include those with significant body surface affected; involvement of high impact areas, such as the face genitals, hands and feet; disease that impacts on quality of life and presence of psoriatic arthritis.
“For example, if you see a patient with palmoplantar psoriasis they can’t stand without being in pain. They can’t shake people’s hands. It’s very isolating,” she said.
The impact on quality of life can be significant. Dr. Cather suggests dermatologists ask several pointed questions, including: “How does this affect you? What do you want to do? What can’t you do? What is this disease preventing you from doing? She noted that some dermatologists might be surprised to hear the impact on the quality of life this disease has.
Understanding the Patient Experience
Numerous biologic agents are approved for psoriasis and psoriatic arthritis (Table 1) and several more are on the horizon. Currently, the main categories of biologic drugs for psoriasis are the tumor necrosis factor (TNF) antagonists (the effector cell cytokine antagonists), ustekinumab (Stelara, Janssen Biotech Inc.), which works on the regulatory cytokines, interleukin 12 (IL-12) and IL-23 and secukinumab (Cosentyx, Novartis Pharmaceuticals), which works on the regulatory cytokine IL-17.
Dr. Cather noted that using biologic treatment in practice can be complicated and the data results are not always reflected in the patient experience. All approved biologics have demonstrated efficacy and safety in randomized, controlled trials and open-label extensions for up to 3 years. However, differences in study design and handling of missing data complicate matters.
“There are meta-analyses showing that the probability of achieving a PASI [Psoriasis Area and Severity Index] 75 with a biologic is 80%.1 But I don’t think 80% of people are happy. And this goes to the fact that everybody is an individual. So if you can figure out a fingerprint of a patient’s psoriasis, how it affects them, you will get higher success rates and it won’t just be a number,” she explained.
It is important to evaluate why patients are considering biologics when they come into the clinic. Patients present for different reasons and at different ages.
“Our practice is a referral center, so the number one thing that comes up is a strong family history of psoriasis or word of mouth. If you have a psoriasis patient who has seen success, they are very interested in biologics,” she said.
Direct-to-consumer advertising is a big patient driver. She noted that patients also frequently say they have seen direct-to-consumer advertising, which can educate patients on the available options and also on the adverse effects that could possibly happen.
“Patients in their late teens and twenties also present at the clinic. This is a time in their lives when their lifestyle is opening up to include alcohol and sex and psoriasis can be an isolating disease that is progressive as a patient ages. It is my job to try to intervene and try to give people some of their life back,” she said.
Physicians, in general, like biologics because they are effective, and they are very safe (Figure 2). “The population in my clinic is two-thirds women. Pregnancies happen. Oftentimes they are not planned,” she said, noting that the safety data is positive. “There is some cardio-preventative data. I look at this treatment as something that will decrease inflammation and help them. Depression and fatigue also improve.”
Good Communication with Patients
Non-compliance is high with psoriasis patients. Dr. Cather recommended dermatologists tell patients before they start the biologic treatment (and again when they return for a follow-up with good results) that if they spontaneously stop their treatment, they will experience fatigue as a precursor to a flare. “They usually understand. That’s part of the education. You connect, you educate and you facilitate change. We would like to facilitate the change of not coming off medications,” she explained.
Patients achieve better results when dermatologists talk about the best way to implement biologic treatment. Discussing with the patient their previous medication history, such as which drugs were taken and what each experience was like, can help select the best option for patients. Dr. Cather suggested asking specific questions in addition to the names of the medications:
• What were you going through at the time of therapy?
• Did you have an infection?
• Did you have a break in therapy?
Behavior modification also can be used to help patients relieve symptoms. In addition, she often provides prescriptions or other recommendations to relieve symptoms (ie, gabapentin for itching or bleach baths for the head for patients who have a staph infection around the scalp or ear.)
“The best drug, the most effective drug, in the itching patient will not clear the disease,” she said.
The Typical Patient
The typical psoriasis patient is on 2 to 3 medications but has compliance issues. They may have additional health problems, including obesity, diabetes, cardiovascular disease or depression.2,3
In addition, lifestyle issues (such as drinking alcohol, smoking) and life issues (stress, economics, demands on their finances, time and competing priorities) may be present.
“I often tell patients there are things that you can control like alcohol and tobacco. I want you to try to get down to your ideal body weight,” she said.
In addition, many patients do not have a primary care provider (PCP) and the dermatologist can help them find one.
Complications of not treating psoriasis include an elevated systemic inflammatory burden and comorbidities, impact on quality of life (physical functioning and psychosocial impact) and economic impact (time lost from work, reduced productivity at work, not being promoted to leadership roles).
Dr. Cather noted that the biologic workup is crucial and should be thorough. This includes skin and joint exams, a full social history, family planning and lab work (Table 2). She noted that when clinical trials are done patient variables are fairly well-controlled. 
“We need to make sure our patients are healthy. For example, we want to make sure our young women have their Pap smears, that the age-appropriate screenings are done,” she said.
Clinical Experience
Dr. Cather provided an overview of her clinical experience with various biologic treatments.
TNF Inhibitors
Dr. Cather selects a TNF antagonist for patients with both skin and joint involvement; concomitant cardiovascular disease, Crohn’s disease and hidradenitis suppurativa.
“If they’re planning pregnancy soon I usually select etanercept (Enbrel, Amgen Inc.). Pediatric patients are usually on etanercept, and there’s a lot of concomitant data with hepatitis C with etanercept and adalimumab (Humira, AbbVie Inc.),” she said.
Ustekinumab
Dr. Cather noted she uses ustekinumab for significant skin involvement, demyelinating disease, obese patients, college students, patients who are afraid of needles, non-compliant patients and treatment-emergent psoriasis on TNF inhibitors.
“For heavier patients and those with major skin involvement, ustekinumab can be life changing. It also works well on patients with joint issues,” she said.
The dose regimen is given in 2 doses at the office, which appeals especially to young adults who want to disassociate their therapy from their life, she added. Non-compliant patients are more likely to stay on in-office therapy.
“Treatment-emergent psoriasis on TNFs can be seen with rheumatoid arthritis patients and Crohn’s patients. They develop a rash. Often they will be clutching their antifungal bottle when they come in. You can biopsy it, but I’m usually just switching them over to ustekinumab,” she said.
Some experts recommend abandoning TNF inhibitors, while others suggest treating through it. Consider the risk-benefit to decide if you should treat through, said Dr. Cather.
Psoriatic Arthritis
Dr. Cather pointed out that psoriatic arthritis provides a clinical challenge and her recent experience over the last few years has brought her to revise her previous thinking on the subject.
“For psoriatic arthritis, you better be in it to win it. The biggest change that I’ve had in the last 2 years is I believe many patients need to be on concomitant methotrexate with the biologics,” she said, noting that she previously recommended monotherapy, which is effective. “However, because this is a disease of a lifetime and adding methotrexate into the treatment is beneficial.”
Data now exists reflecting the worldwide experience with the TNF antagonists for multiple indications. “There is synergy with methotrexate, and methotrexate probably decreases the immunogenicity of all of the TNF antagonists, and probably should be used especially with your refractory patients or patients with psoriatic arthritis,” she added.
Women of Childbearing Potential
Overall, there are fewer treatment options for women with psoriasis, she noted. They can experience sexual impacts from their disease. Family planning should be discussed with female patients. Research shows that 50% of pregnancies were not planned.4
Dr. Cather encouraged dermatologists to have the women who become pregnant while on biologic treatment register with one of the pregnancy registries that exist for etanercept and adalimumab so more data will become available.
For more information, please call The Organization of Teratology Information Specialists (OTIS) at 877-311-8972 or visit www.otispregnancy.org.
Controlling Psoriasis
Today more treatment options are available than ever before. For optimal results, treatment should be individualized for each patient and dermatologists should understand the multiple options that are available because one agent will not work for all patients, according to Dr. Cather. Consultations with colleagues regarding difficult cases can be helpful.
It is important to manage comorbidities and promote overall health and well-being, especially if patients do not have a PCP. Skin cancer screenings are also necessary, especially for patients with a history of immunosuppressive therapies.
Psoriasis is a journey, and dermatologists are part of the journey.
“Try to connect with patients, educate them and facilitate change. It is a group effort. You need to involve the PCPs, too,” she concluded.
Disclosure: Dr. Cather is a consultant for AbbVie, Janssen, Leo Pharma and Novartis. She is on the speaker bureau for AbbVie and Janssen and conducts research for Allergan, Amgen, Celegene Galderma, Janssen, Merck, Novartis, Regeneron, Pfizer, Sandoz, Tolmar and Xenoport.
References
1. Langley RG, Reich K. The interpretation of long-term trials of biologic treatments for psoriasis: trial designs and the choices of statistical analyses affect ability to compare outcomes across trials. Br J Dermatol. 2013;169(6):1198-1206.
2. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006;55(5):829-835.
3. Davidovici BB, Sattar N, Prinz J, et al. Psoriasis and systemic inflammatory diseases: potential mechanistic links between skin disease and co-morbid conditions. J Invest Dermatol. 2010;130(7):1785-1796.
4. Stern RS, Nijsten T, Feldman SR, Margolis DJ, Rolstad T. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc. 2004;9(2):136-139.
The decision of which biologic treamtent to select for each patient can be a challenging one. Jennifer Cather, MD, of Modern Research Associates in Dallas, TX, provided a comprehensive look at the latest biologic psoriasis treatment options with attendees at the Winter Clinical Dermatology Conference Hawaii in January 2015. This article discusses her approach to treating individual patients with psoriasis.
Connect, Educate, Facilitate Change
At the meeting, she discussed the journey of psoriasis for patients and healthcare providers.
“There are 3 things that you can really do that will help patients. We can connect with them and this is important in trying to figure out how psoriasis affects them. We can educate them because we have a significant amount of data, but it’s very hard to implement it for these patients. We also need to facilitate change,” she said.
“If we can connect, educate and facilitate, we will really help patients,” said Dr. Cather, who works with a nurse practitioner to treat about 1,300 patients with moderate or severe psoriasis.
Many psoriasis treatment options exist (Figure 1). Dr. Cather’s presentation focused on biologic agents for moderate disease. Patients with psoriasis who are good candidates for biologic therapies include those with significant body surface affected; involvement of high impact areas, such as the face genitals, hands and feet; disease that impacts on quality of life and presence of psoriatic arthritis.
“For example, if you see a patient with palmoplantar psoriasis they can’t stand without being in pain. They can’t shake people’s hands. It’s very isolating,” she said.
The impact on quality of life can be significant. Dr. Cather suggests dermatologists ask several pointed questions, including: “How does this affect you? What do you want to do? What can’t you do? What is this disease preventing you from doing? She noted that some dermatologists might be surprised to hear the impact on the quality of life this disease has.
Understanding the Patient Experience
Numerous biologic agents are approved for psoriasis and psoriatic arthritis (Table 1) and several more are on the horizon. Currently, the main categories of biologic drugs for psoriasis are the tumor necrosis factor (TNF) antagonists (the effector cell cytokine antagonists), ustekinumab (Stelara, Janssen Biotech Inc.), which works on the regulatory cytokines, interleukin 12 (IL-12) and IL-23 and secukinumab (Cosentyx, Novartis Pharmaceuticals), which works on the regulatory cytokine IL-17.
Dr. Cather noted that using biologic treatment in practice can be complicated and the data results are not always reflected in the patient experience. All approved biologics have demonstrated efficacy and safety in randomized, controlled trials and open-label extensions for up to 3 years. However, differences in study design and handling of missing data complicate matters.
“There are meta-analyses showing that the probability of achieving a PASI [Psoriasis Area and Severity Index] 75 with a biologic is 80%.1 But I don’t think 80% of people are happy. And this goes to the fact that everybody is an individual. So if you can figure out a fingerprint of a patient’s psoriasis, how it affects them, you will get higher success rates and it won’t just be a number,” she explained.
It is important to evaluate why patients are considering biologics when they come into the clinic. Patients present for different reasons and at different ages.
“Our practice is a referral center, so the number one thing that comes up is a strong family history of psoriasis or word of mouth. If you have a psoriasis patient who has seen success, they are very interested in biologics,” she said.
Direct-to-consumer advertising is a big patient driver. She noted that patients also frequently say they have seen direct-to-consumer advertising, which can educate patients on the available options and also on the adverse effects that could possibly happen.
“Patients in their late teens and twenties also present at the clinic. This is a time in their lives when their lifestyle is opening up to include alcohol and sex and psoriasis can be an isolating disease that is progressive as a patient ages. It is my job to try to intervene and try to give people some of their life back,” she said.
Physicians, in general, like biologics because they are effective, and they are very safe (Figure 2). “The population in my clinic is two-thirds women. Pregnancies happen. Oftentimes they are not planned,” she said, noting that the safety data is positive. “There is some cardio-preventative data. I look at this treatment as something that will decrease inflammation and help them. Depression and fatigue also improve.”
Good Communication with Patients
Non-compliance is high with psoriasis patients. Dr. Cather recommended dermatologists tell patients before they start the biologic treatment (and again when they return for a follow-up with good results) that if they spontaneously stop their treatment, they will experience fatigue as a precursor to a flare. “They usually understand. That’s part of the education. You connect, you educate and you facilitate change. We would like to facilitate the change of not coming off medications,” she explained.
Patients achieve better results when dermatologists talk about the best way to implement biologic treatment. Discussing with the patient their previous medication history, such as which drugs were taken and what each experience was like, can help select the best option for patients. Dr. Cather suggested asking specific questions in addition to the names of the medications:
• What were you going through at the time of therapy?
• Did you have an infection?
• Did you have a break in therapy?
Behavior modification also can be used to help patients relieve symptoms. In addition, she often provides prescriptions or other recommendations to relieve symptoms (ie, gabapentin for itching or bleach baths for the head for patients who have a staph infection around the scalp or ear.)
“The best drug, the most effective drug, in the itching patient will not clear the disease,” she said.
The Typical Patient
The typical psoriasis patient is on 2 to 3 medications but has compliance issues. They may have additional health problems, including obesity, diabetes, cardiovascular disease or depression.2,3
In addition, lifestyle issues (such as drinking alcohol, smoking) and life issues (stress, economics, demands on their finances, time and competing priorities) may be present.
“I often tell patients there are things that you can control like alcohol and tobacco. I want you to try to get down to your ideal body weight,” she said.
In addition, many patients do not have a primary care provider (PCP) and the dermatologist can help them find one.
Complications of not treating psoriasis include an elevated systemic inflammatory burden and comorbidities, impact on quality of life (physical functioning and psychosocial impact) and economic impact (time lost from work, reduced productivity at work, not being promoted to leadership roles).
Dr. Cather noted that the biologic workup is crucial and should be thorough. This includes skin and joint exams, a full social history, family planning and lab work (Table 2). She noted that when clinical trials are done patient variables are fairly well-controlled.
“We need to make sure our patients are healthy. For example, we want to make sure our young women have their Pap smears, that the age-appropriate screenings are done,” she said.
Clinical Experience
Dr. Cather provided an overview of her clinical experience with various biologic treatments.
TNF Inhibitors
Dr. Cather selects a TNF antagonist for patients with both skin and joint involvement; concomitant cardiovascular disease, Crohn’s disease and hidradenitis suppurativa.
“If they’re planning pregnancy soon I usually select etanercept (Enbrel, Amgen Inc.). Pediatric patients are usually on etanercept, and there’s a lot of concomitant data with hepatitis C with etanercept and adalimumab (Humira, AbbVie Inc.),” she said.
Ustekinumab
Dr. Cather noted she uses ustekinumab for significant skin involvement, demyelinating disease, obese patients, college students, patients who are afraid of needles, non-compliant patients and treatment-emergent psoriasis on TNF inhibitors.
“For heavier patients and those with major skin involvement, ustekinumab can be life changing. It also works well on patients with joint issues,” she said.
The dose regimen is given in 2 doses at the office, which appeals especially to young adults who want to disassociate their therapy from their life, she added. Non-compliant patients are more likely to stay on in-office therapy.
“Treatment-emergent psoriasis on TNFs can be seen with rheumatoid arthritis patients and Crohn’s patients. They develop a rash. Often they will be clutching their antifungal bottle when they come in. You can biopsy it, but I’m usually just switching them over to ustekinumab,” she said.
Some experts recommend abandoning TNF inhibitors, while others suggest treating through it. Consider the risk-benefit to decide if you should treat through, said Dr. Cather.
Psoriatic Arthritis
Dr. Cather pointed out that psoriatic arthritis provides a clinical challenge and her recent experience over the last few years has brought her to revise her previous thinking on the subject.
“For psoriatic arthritis, you better be in it to win it. The biggest change that I’ve had in the last 2 years is I believe many patients need to be on concomitant methotrexate with the biologics,” she said, noting that she previously recommended monotherapy, which is effective. “However, because this is a disease of a lifetime and adding methotrexate into the treatment is beneficial.”
Data now exists reflecting the worldwide experience with the TNF antagonists for multiple indications. “There is synergy with methotrexate, and methotrexate probably decreases the immunogenicity of all of the TNF antagonists, and probably should be used especially with your refractory patients or patients with psoriatic arthritis,” she added.
Women of Childbearing Potential
Overall, there are fewer treatment options for women with psoriasis, she noted. They can experience sexual impacts from their disease. Family planning should be discussed with female patients. Research shows that 50% of pregnancies were not planned.4
Dr. Cather encouraged dermatologists to have the women who become pregnant while on biologic treatment register with one of the pregnancy registries that exist for etanercept and adalimumab so more data will become available.
For more information, please call The Organization of Teratology Information Specialists (OTIS) at 877-311-8972 or visit www.otispregnancy.org.
Controlling Psoriasis
Today more treatment options are available than ever before. For optimal results, treatment should be individualized for each patient and dermatologists should understand the multiple options that are available because one agent will not work for all patients, according to Dr. Cather. Consultations with colleagues regarding difficult cases can be helpful.
It is important to manage comorbidities and promote overall health and well-being, especially if patients do not have a PCP. Skin cancer screenings are also necessary, especially for patients with a history of immunosuppressive therapies.
Psoriasis is a journey, and dermatologists are part of the journey.
“Try to connect with patients, educate them and facilitate change. It is a group effort. You need to involve the PCPs, too,” she concluded.
Disclosure: Dr. Cather is a consultant for AbbVie, Janssen, Leo Pharma and Novartis. She is on the speaker bureau for AbbVie and Janssen and conducts research for Allergan, Amgen, Celegene Galderma, Janssen, Merck, Novartis, Regeneron, Pfizer, Sandoz, Tolmar and Xenoport.
References
1. Langley RG, Reich K. The interpretation of long-term trials of biologic treatments for psoriasis: trial designs and the choices of statistical analyses affect ability to compare outcomes across trials. Br J Dermatol. 2013;169(6):1198-1206.
2. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006;55(5):829-835.
3. Davidovici BB, Sattar N, Prinz J, et al. Psoriasis and systemic inflammatory diseases: potential mechanistic links between skin disease and co-morbid conditions. J Invest Dermatol. 2010;130(7):1785-1796.
4. Stern RS, Nijsten T, Feldman SR, Margolis DJ, Rolstad T. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc. 2004;9(2):136-139.
