Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 8
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: That is important—the comorbidities—in choosing some of these agents. There's a study out there that looks at the potential for a cardioprotective role of biologics. I think that's important. There's a study where they looked at patients with severe psoriasis who were placed on a biologic and the burden of coronary plaques was decreased. The patients who were not on a biologic increased. So I think the comorbidities have a key role in this. It’s also important to keep in mind that we have a lot of colleagues who do not use biologic therapies. They go back to the cyclosporine, methotrexate, and other agents like acitretin. I think targeted therapies is really the road that ties into the pathogenesis. We learn more about the pathogenesis and we can target these therapies. I think that's key.
Douglas DiRuggiero, PA-C: The only point I want to make with that is when you say biologics and cardiovascular protective, we really only have data that shows that's the case with TNFs [tumor necrosis factor inhibitors]. I'm not saying it's not going to come for the other classes, but as of right now, Joel Gelfand put out a nice study looking at MI [myocardial infarction] and psoriasis risk. We know that if you're 30 years old with severe psoriasis, you have a 3-fold increased risk of having an MI over someone who doesn't. That's linked to severity more than it is overall. But, we also know that with TNFs there may be a reduction of as much as 50% in your incidence of MI.
I think we're going to see cardioprotective effects and other effects with metabolic syndromes with some of the other classes too, but we can only say that with confidence with data in the TNF class.
Melodie Young, MSN, RN, ANP-C: I think so. When you're looking at controlling the inflammatory burden of the disease as opposed to just thinking about controlling the signs and symptoms—doing things to reduce the flake, reduce the itch—you have to think of it as, how can I help control the inflammatory burden? As Margaret said, specifically if affecting the cytokines that are most specific in psoriatic diseases.
As Douglas mentioned, the earlier therapies that came to psoriasis and came into dermatology after they had been used in a lot of other disease, such as severe diseases like severe rheumatoid arthritis, we are fortunate that we had access to those. But now, a lot of these therapies, if you look at the IL-23s, particularly, are only being used in psoriatic disease and in skin psoriasis and plaque psoriasis. So they're very, very specific. As we look at the sort of baggage that may have been brought in, and the black box warnings, these came from trials associated with other disease therapies or other disease treatments. Whereas now, we're looking at treatments specifically for psoriasis.
We want to talk about all of them because I, too, like Douglas, use absolutely every one of these therapies. And I'm sure that all 4 of us on the panel, we use anything and everything.
Douglas DiRuggiero, PA-C: I don't have anyone on Remicade [infliximab], because I don't really have great access to an infusion center. But regarding all of the ones that you can either inject in the office or the patient can self-inject, I have many patients on them.
Melissa Davis, PA-C: Or brodalumab, because of the REMS [Risk Evaluation and Mitigation Strategy] program. I don't have anyone on that.
Melodie Young, MSN, RN, ANP-C: I have patients on both of those, and I think that's also what's fun and interesting about our profession. You want to have a lot of different options, but the crazy thing about this disease is we do not yet have 1 drug that's going to be 100% effective for 100% of patients with minimal adverse effects. There are some nuances to knowing which therapy to pick, what things you have to watch out for, and which things you should avoid. Certain patients should not use certain therapies. One of the things, for example, is with TNF inhibitors, which have been a godsend to so many people for so many diseases and we're going to be using those for other things, but there are certain patients who should not use a TNF inhibitor. That's been the progression of the science.
Transcript edited for clarity.