Multidisciplinary Perspectives on the Management of Plaque Psoriasis - Episode 5

Assessing Individual Patient Needs With Plaque Psoriasis

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Mark Lebwohl, MD: I’m going to move on to a subject that really impacts our colleagues. How do you pick a particular drug? I always hate getting the question asking which drug is the best. Every pharmaceutical company thinks its drug is the best. Until you get a patient with a contraindication to that drug. I’ll start this question with an anecdote, and the question is, what is your approach to assess how to treat each individual patient? I had a talk to give at a National Psoriasis Foundation patient meeting. There were 107 people in the room, and I asked everyone to stand up. I said that at the end of this list of conditions I’m going to read, if you’ve had 1 of the conditions, I want you to sit down.

I started with: Do you have joint pain or psoriatic arthritis? Are you overweight? Do you have Crohn disease or ulcerative colitis? Do you have multiple sclerosis? Do you have lupus? Have you had hepatitis B or C, or do you currently have hepatitis B or C? Do you have HIV? Do you have risk factors for cardiovascular disease, like smoking, a family history of heart attacks, a personal history of heart attacks, hypertension, or diabetes? Have you ever had a malignancy of any kind? I had a couple more, like congestive heart failure. I said, “OK, if I mentioned a condition that you have, sit down.”

Of 107 people, 1 person was left standing. So I really hate when an insurance company says to me, “You have to use this drug first because they’re all the same, and this is the 1 we want to use first.” It is so contrary to what we are taught in terms of doing what’s best for a patient, so we’ve published a couple of articles that get cited a lot about which drug do you give to which patient. We go over all these comorbidities. How would you answer that question when you get asked, which drug is best?

Philip J. Mease, MD: I don’t. In fact, I have a little resentment about the question. You hit the nail on the head, Mark. Every patient is an individual story, and every patient has certain comorbidities that need to be taken into context when we are making a choice. Every patient has a knowledge of someone in his friendship network or a relation who has been on medication before, and they may have preconceived notions, so it’s a conversation that occurs.

Our role is to lay out the data on relative efficacy and safety, mode of action, how it’s given, and cost. They’re providing us with, “Well, I’m a patient, but I’ve got this background story that is rich with all those issues that we just talked about.”

Multiple sclerosis, for example. That would be a signal to us that we shouldn’t use a tumor necrosis factor inhibitor, for example. Or if the patient is morbidly obese, we should probably avoid something that’s going to cause liver toxicity because they may have fatty liver, which is going to predispose them to other problems. We have to be holistic health practitioners to take all this in, to impart education, and then come up with a decision about if we’re going to do this now, and then if this happens, we’re going to do this and this. It’s a whole process.

Mark Lebwohl, MD: The next question I want to address is really more for me than for you. At what point in the treatment of psoriasis do I seek a rheumatologist’s help? We’ll see if a patient has any significant disease. If they have trivial disease that they hardly complain about. I might not send them to a rheumatologist, but if they have significant disease, you do things we don’t do.

I have no education about physical therapy. There are some diagnostic maneuvers that you can do that I am just not going to be good at. Injection of joints is something that dermatologists simply do not do, so if somebody has any significant degree of disease, I’m going to comanage them with a rheumatologist. I would say, certainly in my practice, that is common.

Transcript Edited for Clarity