Matthew Brunner, MHS, PA-C, DFAAPA  

We’ve covered a lot. We talked about topical treatments, we touched on phototherapy, we talked about the oral treatments, and then the different class of biologic agents, including the TNF [tumor necrosis factor]–alpha inhibitors, IL-17s and the IL-23s. That’s what’s exciting: there’s even more research that’s happening in the field of psoriasis, and there are new agents coming into the field. Can you talk a little about what’s coming down the pipeline?

I’m really excited. First, we have just seen such an explosion of immunology, knowledge, education, and therapeutics in the last 20 years. And that knowledge and advancement’s continuing. There are new classes of immunologic agents called tyrosine kinase inhibitors [TKIs], and they’re hopefully going to be entering the fray very soon. They’re going to offer another modality and an oral agent that patients will be able to take, hopefully with more convenient dosing options and good safety. We’ll see all that come to fruition.

Then there’s this topical therapeutic aryl hydrocarbon receptor modulating agents that are being studied in both psoriasis and atopic dermatitis. And we may see those in both topical and systemic iterations down the road. The future has never been brighter to be a psoriasis patient. I tell my patients all the time, it’s never great to have psoriasis, but you’ve never lived at a better time to have psoriasis. Every time I see them back in a future visit, the same holds true because new agents are coming—new targets, to help them manage their condition—are being brought to market. It’s really exciting. What do you think about the future?

 You said it very well. It’s such a great time to be in the field of psoriasis management because there continues to be such activity and research. We have very passionate researchers who are really looking to find a cure. In the meantime, finding all these targets that help improve the skin, help improve the joints. There new agents coming out, but it’s also important to understand that, for example, with the IL-23s, there are new indications being studied. Right now, many of the IL-23s are indicated for moderate to severe psoriasis in adult patients. We’re going to see clinical trials that are being completed currently in adolescents and in pediatrics. That’s something that we can look forward to. Also, we can look forward to data that are going to be coming shortly about psoriatic arthritis and the use of IL-23 inhibitors in psoriatic arthritis disease. That’s going to be very promising as well.

You said it perfectly: the future has never looked brighter for our patients with psoriasis. As we move toward the goal of clear or near-clear skin and also looking at them holistically, helping prevent the development or worsening of those other comorbidities—such as metabolic syndrome, psychosocial disease, and cardiovascular risk—all these treatment modalities can help us help our patients with psoriasis to live long and healthy, happy, successful lives. That’s our role as NPs [nurse practitioners] and PAs [physician assistants] in dermatology. It’s a very exciting time.

Thank you for joining me today. This has been really a fun conversation. Hopefully it’s been educational for those of you watching. Thank you for watching 

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Matthew Brunner, MHS, PA-C, DFAAPA, highlights the most anticipated developments in the field of treating patients with plaque psoriasis. 

Anticipated Developments in the Field of Plaque Psoriasis

 One of the things I’m curious about is does it make a difference if a patient is biologic naïve and comes to you with moderate to severe psoriasis, vs a patient who has been on several biologic agents? Does that change how you approach which agent you’re going to put them on?

 It does, actually. For the patient’s biologic experience, I want to know what biologic they took and what their experience was. What adverse effects did that patient experience? Did they have a good experience? Did it work well for them? Was there some reason, such as loss of insurance, that they had to interrupt that? And if there wasn’t a reason not to restart that therapy. I will usually restart the patient on that therapy. If a patient had a loss of efficacy, they were unsatisfied, they had some adverse effect or lab abnormality, I will absolutely switch them to a different class. For the biologically naïve, approach them based on their comorbidities, their presentation, and what’s important to the patient. I approach them differently, but those are some of the nuances in terms of selecting an agent for them.

 One of the things about being a nurse practitioner [NP] and a physician assistant in dermatology is that we often manage the chronic diseases in dermatology, such as psoriasis and atopic dermatitis. Some of the roles that we play in the management of plaque psoriasis is that we can take the time to develop a relationship with these patients, spend some time educating them about their disease, reviewing all the treatment options that are available, and then really working with the patient to come up with a decision that’s going to be helpful for the patient and that the patient can live with and be successful with.

Nurse practitioners and PAs [physician assistants] can impact the quality of life of these patients with psoriasis and psoriatic arthritis. The most rewarding days I have are when I see those patients come in who were covered head to toe or who were just miserable in pain, who were socially isolating, but they happen to be on a good agent for their psoriasis and feel like they have a new lease on life. They’re engaging in their family activities. They’re holding down jobs and successful. They’re traveling and going on vacations. They’re going to the gym and working out, and subsequently, their diabetes is getting better under control. They’re losing weight. You can really see the transformation in these patients, and that’s something that’s really, as an NP, I really value. As a PA, Matt, you’ve seen these patients and transformed their lives, and it can be remarkable. When you counsel patients about psoriasis, what are some of the challenges you face in helping patients come to terms with their psoriasis and then helping them move past them and be successful in their treatments?

The first challenge that I would like to pinpoint is helping patients accept the chronicity of their disease. Many patients come in with the expectation that there’s something we can give them, something we can do for them that’s going to make this problem go away. It’s important to have that discussion, as we’ve mentioned, over the chronicity of the disease. You pinpointed that those patients sometimes have trouble with compliance with their therapies.

Sometimes that’s because we’ve taught them that with topical therapies, they should use them intermittently. We have to make sure we educate our patients when we put them on a systemic agent, whether it’s an oral agent or an injectable agent, to understand that these are not intended to be intermittent therapies. These are therapies that patients are meant to initiate and stay on, unless there’s a reason the provider stops them from their therapy, or they’re having some health concern that they need to stop it. Because patients have become accustomed to using topical agents intermittently, they sometimes transfer that into systemic agents. We have to do a better job as practitioners of educating our patients on that.

The other part is helping patients know when it’s appropriate to hold their objections if they’re on a biologic agent to recognize those concerns, but it can be challenging sometimes to coordinate with the rheumatologist or their primary care provider. Being able to communicate effectively as a part of the care team, with the other individuals who are responsible for the patient, is another crucial part of the puzzle.For the biologic naïve, it’s ]approaching the patient understanding their comorbidities, understanding their concerns. Will they feel comfortable? Was the patient more comfortable with us giving the injection in clinic? Is this something that would not at all fit for their lifestyle? That’s the proper approach to helping the patient and having that discussion about the appropriate education for them.

Stratification of patients for the treatment of plaque psoriasis based on comorbidities and prior biologic experience.

Stratifying Patients With Plaque Psoriasis for Treatment With Biologics

 Let me ask you this. If a patient starts to lose efficacy in 1 class, do you try them on a different class altogether? Are you comfortable, or do you think there’s value in staying in class and trying a different agent within that class?

The first part is what’s considered a treatment failure. If I’m seeing the patient back for 1 interval follow-up, and they’ve been doing well, where they recently started to worsen, I’ll have a discussion with him about giving it some time. We know there are triggers, as we mentioned earlier in our conversation. Patients may experience a loss of job, a physical illness, a hospitalization or surgery—some sort of a trigger for their condition. That’s true even in patients on systemic agents who are very strong and aggressive, like biologics. I like to see the patient back again after another 3 to 4 months and see how they’re doing. If the patient is continuing to show worsening of condition or lack of control, and I consider anyone who has more than 3% BSA [body surface area] to be losing efficacy on these systemic agents. If they’re losing efficacy, it’s time for us to move the therapy. If they’ve been a responder to a class, I have no trouble putting them on another agent in that same class because I know that mechanism of action has worked well for the patient in the past, and I assume that they’ve developed other antibodies or some other reason why that agent’s no longer working. I’ll move them to another agent, unless there’s some other presentation that leads us to consider moving to another class. How about you?

 You summed it up perfectly. There’s definite value if a patient has gotten really good results with 1, for example, TNF-α inhibitor [tumor necrosis factor-alpha]. Before completely jumping ship and going to a different class, I’d definitely try a second TNF-α inhibitor, especially if they have psoriatic arthritis or other comorbidities. If they’ve had a good response, I’m more apt to stay within class and try a second agent. If I start them in 1 class and they’ve gotten absolutely no response, then I might try going to a different class. Looking at their profile, understanding their comorbidities, if a patient doesn’t have joint disease or a lot of comorbidities, I might put them on an IL-23 first or even an IL-12/23 inhibitor. That’s a decision I would consider. It’s important to look at the whole picture. What has the patient tried before? How long did they use the medication? Did they get an initial good response? Did the response wane over time?

Another really important question is, were they using the medication properly? Were they consistent in taking the injections? Sometimes what happens with biologic therapy is they can be so effective that patients will think that they’re cured, or they’ll try to make their doses last longer and skip 1 here and there. That can also affect efficacy. It’s really important to have an honest conversation and make sure patients are using the treatments appropriately and also to see what’s going on in their life. If you have a patient who has been doing great on a medication and you see them back, and they’re just flaring horribly, before talking about it being a complete failure of the drug, ask them what’s going on in their life. Have they been more stressed? Have they had any other recent health issues? People can get the flu and see their psoriasis worsen. If they go in for surgery, the stress of that surgery might cause their psoriasis to worsen. They might go on vacation with their kids, and that can be stressful. It’s important to understand what’s going on in their life before you think about throwing an agent out as a treatment failure. You had mentioned that too.

Advanced practice providers discuss scenarios in which they would consider switching between therapies when treating patients with plaque psoriasis.

Switching Therapies for Plaque Psoriasis

We have 3 of these agents. We have tildrakizumab, which is dosed at weeks 0, 4, and 12; guselkumab, which is dosed at 0, 4, and 8 if I’m not mistaken; and then risankizumab, which is also dosed at weeks 0, 4, and 12. Can you tell me about your experience with each of these 3 agents?

 The first agent that came forward and was FDA approved was guselkumab. We were excited with that. I’ve had patients who’ve had both skin and joints significantly improved with guselkumab 100 mg. The dosing is week 0, 4 weeks, and then every 8 weeks thereafter. In the clinical studies, what we saw was that about 70% of patients with moderate to severe psoriasis had 90% improvement in their symptoms at week 16. With just 2 or 3 injections, they had 90% improvement in their symptoms. You mentioned those symptoms. It’s not just how their skin looks but that itch and that burning that are incredible.

Tildrakizumab is the second 1 that was on the market for an IL-23. What we’ve seen with that is about 63% of patients who have moderate to severe psoriasis see at least 75% improvement in their skin symptoms at just after 12 weeks, so 3 months of treatment. After 3 injections, patients are seeing significant improvement in their symptoms.

Risankizumab is the most recent lL-23 inhibitor that hasn’t been approved for the treatment of psoriasis. We saw high numbers: about 78% of patients with moderate to severe psoriasis who saw at least 90% improvement in their skin symptoms after just 12 weeks of treatment. The take-home point with these IL-23 inhibitors, what I tell them is they can expect really rapid improvement in their symptoms, and we expect them to get clear or near clear at least in 3 months’ worth of treatment. It’s rare that those patients don’t respond. Every now and then, you do get a patient who doesn’t respond as effectively. I have a very high-risk psoriasis clinic, so patients have recalcitrant disease with lots of comorbidities. There are a handful who don’t respond as well as we saw in the clinical trials. But in general, the efficacy is nice and the safety has been reflective of what we saw in the clinical trials and in the long-term safety data. Then again, the dosing has been convenient for them. The challenges with the IL-23 inhibitors and with any of the biologics is being able to get it to the patients who need it. Sometimes in underserved communities who may have challenges with insurance, it can be a challenge to get these medications into their hands. What’s been your experience with IL-23s, Matt?

It’s interesting. When we first were going through the expansion from TNFs [tumor necrosis factor] into IL-17s and the IL-23s, it was this time of turmoil in dermatology because there were so many new agents. They really had a lot of new opportunity to help more patients. At this point, we had a lot of patients who were failing our TNFs and even failing ustekinumab. It was nice to have some options. I’d still really like to use my TNFs and my IL-17s in patients who have really aggressive psoriatic arthritis. For patients who may have milder to moderate or PSA [prostate-specific antigen], I will be a little quicker to reach from IL-23 agents just because the safety, as you mentioned, really does stand out as 1 of the differentiators in the class of drugs. It’s interesting, and I use all the agents, with the exception of infliximab, but each patient has their own reason why they’re on that agent. You’ll have patients who may have an injection site or reaction to 1 agent—they don’t tolerate that agent, so you’d have to move to a different 1. Or a patient who has recurrent abscesses or boils on 1 agent but can use a different 1 in the same class. It’s interesting to me that there’s a place for each of these drugs and all our patients, but I’m very comfortable with the IL-23 class. It’s my go-to starting class unless I have a reason why a patient may need 1 of the other agents. It’s something that stands out on its own.

But I love having all these agents. It’s amazing to be able to help patients who are in different places. As we see with all psoriasis treatments, even the biologics, there is wear-off effect. That’s unfortunate. Not every patient experiences that, but a good number of them were affected. We used to call that tachyphylaxis when we’re talking about topical therapy that patients would use for some time and it no longer seemed to be effective. But the same thing transfers into the small molecules or oral agents as well as the biologics. There’s this wear-off effect, and I don’t think it’s just about noncompliance. There is really something to it in terms of the immune system getting around the therapy.

Lakshi Aldredge, MSN, ANP-BC, DCNP, and Matthew Brunner, MHS, PA-C, DFAAPA share their personal experiences with using IL-23 inhibitors in treating patients with plaque psoriasis.

Matthew Brunner, MHS, PA-C, DFAAPA

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