Douglas DiRuggiero, DMSc, PA-C, Skin Cancer and Cosmetic Dermatology Center 

Before we sign off, I’d love to hear from everyone any advice or practice pearls for other APPs [advanced practice providers] that are either new or established in the management of plaque psoriasis. Darren, let’s start with you.

Try your best to get your office to get you a good biologic coordinator, because no matter how much we know and can prescribe these medications, having a team effort in the access of these medications is very important. I know recently they had a biologic coordinator day. We’re getting more and more recognition in this, but you have to have somebody you can work with. Advanced practice providers seem to be the default providers who see psoriasis anyway, so we really want to make it streamlined as much as possible. Our patients deserve the best. We take the most time with them, it seems. I’m always spending as much time as I can with them until I’m forced out of the room. I love these medications. These are incredible.

Our toolbox is definitely full, and to Doug’s point, the quiver is full. There are so many different weapons we can use now. It is incredible. We just have to feel safe and comfortable with a lot of these. We’ve had a lot of years of using biologics and small molecules now. And there are different medications and newer creams are coming out, and you just have to use them. That’s going to be the biggest thing we can do—have a whole team that works with this. I know the companies are helping us a little with some of this access to medications, but we want to make sure everyone has access to it. And being a team player with someone in your office, like a biologic coordinator, is my biggest help. Otherwise, it’s daunting. It’s just too much work.

What’s kind of amazing is pharmaceutical companies are now sponsoring biologic coordinators to be speakers for their company to help other biologic coordinators get medication approved. I love that so much. Because there’s only so much that we know and so much we can help our biologic coordinators with and vice versa. It’s just like us talking with our peers and colleagues. It’s the same thing, and I love that that community is blowing up.

Absolutely, and they deal with all the patients. They’re the ones talking. They’re making the phones calls. They’re behind the scenes. We know the medications, we prescribe them, and it’s great, but they really do a lot of the background work and all the hard work in some cases.

There’s a biologic coordinator council and society now. They have a journal and a publication. Last month, I received the first publication of biologic coordinator council, so it’s really neat to see all that happen.

For APPs who potentially want to expand their knowledge of psoriasis and the toolbox and things we use—I know sometimes I hear that it’s a little daunting just because we have so many tools now. When you look at clinical data, I would encourage to look at not only your primary end points but also a little further out. Look out to week 52 or week 60. It kind of gives an understanding or a general feel of the trajectory of medication. Then also looking at data out a couple years down the road that maybe some companies will have. Some companies publish that as that comes out for you to understand what you may see in your clinical practice, and each medication is going to work a little differently. So its not just primary end point but some of these longer end points, too.

There are certain nuances, like with deucravacitinib. Just because they monitor for certain things doesn’t necessarily mean there’s a high incidence of safety events. Clinical monitoring is not always 100% correlated with clinical incidence. That’s something that is the other nuance, too, with medications. With some medications, clinical incidence is more frequent, which is why we justify monitoring for certain safety signals. It’s kind of just teasing out those nuances. It does get overwhelming sometimes. And like what Darren was saying with bio coordinators and them understanding the insurance part and helping us through that guidance, that is a super useful tool for us as clinicians, for the paperwork and getting medications to our patients.

The labor of love for us as clinicians is understanding the products we’re using. At least now the products and medications we’re using have delivery of really high outcomes in a tolerable vehicle for our patients. It’s kind of just grouping your medications and trying to decipher which way you go and almost having a playbook for your psoriasis treatment on how you stratify your topicals, how you stratify your systemics, and then templating it. A lot of times, having a system may help you through this process, too. It’s kind of our own flavor of what system works best for us as individual clinicians.

Awesome. Jayme, what pearls do you have, whether they’re educational or clinical? Is there anything you would give advice on for other practitioners?

I think we have a responsibility. We need to be that beacon of hope for these patients. They have such a physical and emotional burden for their disease. It’s very hard. We also have a responsibility to support one another. I feel very lucky to say I know the panelists here today, and I have a great deal of respect for them. It’s really nice to be able to reach out to somebody. Even if somebody I don’t even know were to reach out, I would be more than willing to help them just like I help the other colleagues in my office.

We always need to make sure our patients get what they need. Sometimes it’s just making sure we know all our resources. Like Darren said, it is just an invaluable resource to have a biologic coordinator. It’s very difficult. We need to know all these programs. We need to know how we can get access for our patients. To do that, we need to continue reaching out to one another. We need to continue to support one another, we need to educate one another, and we need to educate our patients. We need to always let patients know that when they leave, they are supported, we do care, and we are going to help them. That’s our commitment to dermatology, and that’s why we have been entrusted as PAs [physician assistant] and NPs [nurse practitioner] to go ahead and take on this dynamic role to help patients with psoriasis.

Douglas, do you have any advice or any practice pearls for other APPs, whether new or established, in managing plaque psoriasis?

I can only echo what my great colleagues have already said. There’s obviously a theme here: get to know the medications, take the time to understand these medications, and practice presenting them to patients. Maybe you practice by pulling your nursing assistants together and say, “Let’s talk about these medications.” Maybe you meet with colleagues that are in your office. Maybe you reach out to someone you met at a conference, or reach out to any of us. I know we’re all willing to talk to people. There’s a great supportive network in the NP and PA community, as well as with our physician supervisors.

We want to do what’s best for our patients, so the takeaway pearl is to realize the power you have at your disposal. This is not power that’s meant to lift you up. It’s power to be transferred to your patients to change their lives. What an awesome opportunity it is to do that. My pearl is to take a little bit of time. If you got into medicine and you don’t consider yourself a lifetime learner, then you may be in the wrong place. Because if you’re not a person who’s willing to get up sometimes on a Saturday morning or stay up a little bit later—I’m just a believer that what you do from 9 am to 5 pm is not as important as what you do between 5 pm and 9 am. It takes a little bit of some buy-in to be someone [who’s] going to be on the cutting edge, that’s going to be evidence based, and that’s going to be empathetic. That empathy is shown by giving patients the best options we have. Your patients deserve it, they love it, and we’re all capable of doing that. It makes it fun. That’s my encouragement to you—be a prescriber of hope. Tell patients we’ve got great things- there are great things available to them. Speak that positivity into their life when you first see them, because that begins to change things right off the bat that I’ve seen at least in my practice.

Darren, I think I cut you off before. Was there anything else you wanted to add?

We have an obligation to treat our patients, and I think we do a disservice to our patients when they walk through the door, take the time to come in and see us, and we just give them a cream and turn them loose. We need to understand these medications. We need to understand how well they work. We need to give our patients hope. I think that’s why they come and see us. I think the advantage of us being in this industry today is that we have so many tools to work with. We have the advantage on our side, and we can change lives forever. It’s incredible. I’m glad we’re a part of it these days. The companies that have put a lot of effort and work into getting these drugs to market, and the research and development we see today, is incredible. We need to all work together. We don’t have all these amazing drugs just to sit on the shelf. We need to be bold enough to try them out. We need to be not fearful in prescribing these and just jump off that ledge and do it and see how it works.

I’m not saying this, but I’ve heard others say this—others that are much more influential and are in this space. They feel like we’re getting to a point, very close in time, that not offering a patient who has severe disease a systemic agent—I’ll keep it in the category of severe—may be considered malpractice in the near future. Because we know, with severe disease, the chance of them creating a destructive joint, having a heart disease, and all the other problems we’ve mentioned—not addressing that is something that is such a disservice. I’ve heard others who are far more influential than me make those bold statements from the podium. I’m not sure I’m willing to make that bold of a statement from a podium yet, but I sit there and shake my head and agree. We’ve got these tools and we’ve got to put them to work.

Think about deciding to not treat an uncontrolled diabetic. We have to get into that mindset of the systemic condition, and I think that is changing. Psoriasis is no longer a skin condition. We just talked about all the comorbidities, all these things that come along with it, and we have to continue to relay that message to each other and our patients. I think we can always continue to learn, like Douglas said.

Thanks to all of you for this rich and informative discussion. Thank you for watching this 

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Experts in dermatology share practice pearls to advanced practice providers and community dermatologists for the management of plaque psoriasis.

Clinical Pearls and Educational Needs in Plaque Psoriasis

Jayme, given the recent approvals for the management of plaque psoriasis, what unmet needs still remain in both research and clinical treatment of these patients?

There’s always going to be a number of medications we have; however, not all medications work for each person we treat. We’ve learned this from previous experience. Sometimes even from class to class, with certain IL-17s, a patient may do very well on it and then they don’t do as well. We may use another IL-17 and they do extremely well again, or we’ll go ahead and use an IL-23 or an TNF [tumor necrosis factor] inhibitor. We really don’t know. There’s a lot of research being done to try to genotype patients with plaque psoriasis to identify whether they respond to a certain group of medications more so than other groups of medications. I can tell you, being a provider for almost 2 decades, that treating patients with psoriasis is very humbling, because just when you think you have it figured out, something else happens.

The 1 thing we know is that there’s additional research that is ongoing. Do we need additional medications within the psoriasis space? Yes, we do. We just need to identify more. We have certain conditions, like palmoplantar pustular psoriasis, and we really don’t have a good medication for that. We do have medications coming out, whether they’re biologic therapies, and there are different small molecules that are coming out. There’s always room for everybody at the table when it comes to treating patients with psoriasis.

There is a true unmet need in regards to oral therapies for pediatric populations. For the pediatric population, we do have injectable therapy or methotrexate therapy, but we also have all the problems that come along with treating with methotrexate therapies—the frequent blood draws, the monitoring, and everything else—not to mention the fact that, with girls of childbearing age, it’s contraindicated. So, it’s really nice to know there are small molecules that are being tested to treat patients aged 12 to 18, and that’s really important.

Scalp psoriasis is another area that is very difficult to treat….We’ve tried a lot of biologic therapies. We also have a lot of studies that have been done with the current biologic therapies that we have looking at scalp psoriasis. There are also small molecules being used to treat scalp psoriasis. One of those that are in the development right now is deucravacitinib, which we talked about earlier. It’ll be really interesting as time goes on as other molecules are developed within this space to help patients with psoriasis.

Jayme M. Heim, MSN, FNP-BC, discusses unmet needs in the treatment landscape of plaque psoriasis.

Unmet Needs in Plaque Psoriasis Treatment

We’re jumping into this last section here, talking about future directions and some of the unmet needs we have for our patients. Douglas, how do you anticipate the impact novel and emerging treatments for plaque psoriasis will have on patient quality of life and disease outcomes?

Well, everything Darren just said is an indirect answer to this. We have a new novel medication that’s in our hands right now. With this novel medication, we have the opportunity to offer patients something oral. Any time something new comes out, I want to know a couple questions answered in my brain. When I sit in a product theater, or I’m at a conference, when I listen to a virtual presentation, I want to know, is it safe, and does it works? Underneath the category of "does it work", does it work well? Does it keep working? And does it work better than what we already have?

It’s been tough I think for deucravacitinib. It’s got a lot of answers that it has to provide for questions. When we get these new novel emerging therapies, we want to have those questions answered. In the trials, it compared itself with apremilast, both looking at safety and efficacy data. We’ve been writing apremilast since 2014 when it came out. We all have experience with apremilast, but we know it can cause some nausea, vomiting, changes in stools, and there are some questions you want to ask about this depression. So deucravacitinib needed to make sure the audiences know that it didn’t see any nausea, vomiting, or diarrhea problems, and it never saw any signs of depression or suicide. So that satisfies those direct issues you have with the current medication.

Then they have to talk about whether they’re like the other JAKs [Janus kinase inhibitors]. And as one of my colleagues already said: Do we have to have all the same concerns of the 5 black box warnings? Good for us, the FDA has taken that pressure off of us. But that doesn’t mean that, with these novel therapies that are here to stay, we don’t have to do our due diligence with asking the right questions and selecting the right patients. We’ve got a lot more patients that are going to be right on this medication.

To answer your question more directly, isn’t it exciting that we have these novel topical things that are coming out—and we haven’t gotten into that—but we have novel topicals, new compounds, and new molecules. We now have these new classes of intercellular interrupters of gene transcription with these JAKs and now in TYK [tyrosine kinase inhibitors], which is a type of JAK. And we still have our monoclonal antibodies and our other orals. We have so many arrows in our quiver that we can shoot at this disease, and the reason for this is to improve patients’ lives. That’s our No. 1 concern. That’s why I got into doing medicine. It’s why I still love doing what I do, because I see patients’ lives change.

Douglas DiRuggiero, DMSc, PA-C, reviews how deucravacitinib impacts the quality of life for patients with plaque psoriasis.

Impact of Newer Plaque Psoriasis Treatment on Patients’ Quality of Life

So Darren, how often is treatment or follow-up required with deucravacitinib therapy, and how does this compare with some of the other therapies that are out there for plaque psoriasis?

I have limited experience with this medication, but I’m very hopeful that this is one of those medications I can put my patient on, follow-up in a couple months, and see how they’re doing. You do want to follow-up with these patients. We’re not going to just turn them loose. This medication reminds me a little bit of how the TNF [tumor necrosis factor]-alpha medications were 20 years ago. We just didn’t know what we were getting into. We didn’t have enough history. We didn’t have the data or the clinical experience to support the data. We were just always treading lightly on this ground. So with this medication, I would be similar. We’re going to write the medication, follow-up with them every 3 months, and just see how they’re doing.

I think medications that are oral, have fewer side effects, and require less monitoring are appealing. It’s appealing to all of us who have had a lot of history with these medications. Obviously, we’re going to follow similar guidelines—maybe not to the extent of the JAK [Janus kinase] inhibitors….Those of us who have patients on the JAK inhibitors, we’re very selective with our patients and we’re careful. But all-cause mortalities, lipids, [increased dichlorodiphenyltrichloroethane]—those are things that scare us, and we’re not seeing those types of things with this TYK2 [tyrosine kinase 2] drug and this TYK2 inhibitor. I would follow-up with them routinely, keep them going as much as we can, and hold their hand and educate them along the way.

However, the FDA approves this drug. When the FDA approves a medication, they’ve gone through the scrutiny of it. As advanced practice providers, we must trust our gut but also trust how these medications get approvals. We need to have some confidence in that. That’s how we have to approach this. Yes, follow up with and monitor your patients but also give them some space. Let them go and see them routinely, as much as we can, without overburdening them.

Thankfully, we don’t have to do what some of the disease-modifying antirheumatic drugs and other medications that we have, have required. That’s where it’s been a burden for a lot of us providers with certain medications, but I think we’re getting away from that. A year from now, if you ask me that same question…we’ll probably be writing it commonly and will have very little thought on how much we regulate and how much we monitor our patients.

Darren West, MPAS, PA-C, shares how often follow-up is required with deucravacitinib therapy in plaque psoriasis.

Douglas DiRuggiero, DMSc, PA-C, Skin Cancer and Cosmetic Dermatology Center

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