Multidisciplinary Perspectives on the Management of Plaque Psoriasis - Episode 4

Challenges in the Management of Psoriatic Arthritis

November 16, 2020


Mark Lebwohl, MD: Can you talk to us about some of the challenges you face in managing patients with psoriatic arthritis?

Philip J. Mease, MD: The obvious 1 is what you’ve alluded to, which is patients are worried and anxious —especially during the pandemic—about taking medications that have immune-moderating or immune modulating properties. They have the word immunosuppression in their minds when they’re using the various effective medicines, like biologics or targeted synthetic disease-modifying antirheumatic drugs, so 1 of the first things we need to address is what’s the reality behind that concern or fear. I won’t diminish that severe infections can occur, but I will also try to put in perspective that the rates are low and that the rates of other adverse effects besides infection are also very low but not nonexistent. We have to talk about them, but they are very low. When you balance that against the value of using medicines to diminish inflammations, to diminish pain, to improve function, to improve quality of life, to improve work status, and also potentially to diminish some of the downwind effects of chronic inflammation in the body, including cardiovascular disease. These are all things that we have conversations about, and we do our best, and our staff does its best in trying to find the most modest expense for the patient. That’s thinking through what’s going to be effective yet not cost a home mortgage for the patients to take, and there are many programs that the pharmaceutical companies now offer for non-Medicare patients to try to reduce the cost of co-pays and to reduce the cost of medicines. Hopefully, you can start to take that out of the discussion and focus on the seesaw of cost benefit for potential adverse effects that you’re trying to put in perspective.

Mark Lebwohl, MD: It’s interesting that when I have the conversation with patients about the adverse effects, and they all hear these ads on TV about infection and malignancy, and that really stays in their mind. I’ll point out to them that older drugs, specifically tumor necrosis factor [TNF] blockers and certainly the very old drugs, like methotrexate and cyclosporine, were unequivocally associated with infections and malignancy. They have black box warnings about infections and malignancies; new drugs don’t.

In fact, if you look at the package insert for the new drugs, the word immunosuppression does not appear, and if you look at some of the new drugs in the oral realm, apremilast is a phosphodiesterase inhibitor; so is caffeine. The adverse effects that occur with apremilast are diarrhea and weight loss. The diarrhea is temporary and generally resolved within a couple of weeks. The weight loss, most of our patients want. And headache are usually mild to moderate and self-limited.

With the IL-17 blockers, there are people born with that IL-17, and they get yeast infections, they get chronic mucocutaneous candidiasis. They don’t get more malignancies, they don’t get more heart attacks, and all the data look like they’re not going to get more malignancies or heart attacks. For the patients on the IL-23 blockers, the closest example we have to that is people born deficient in p40, or people who have been treated for years with ustekinumab.

They get salmonella. People born deficient in p40, that’s IL-12 and IL-13, get salmonella infections, which has not been reported in patients on these drugs, and they get microbacterial infections. We’re going to get a tuberculin test once a year, and I say to patients, “We could have predicted that our patients on the latter 2 drugs would do well with COVID-19 [coronavirus disease 2019] because there’s not an increase in viral infections.

If you look at TNF blockers, the picture is not as clear, but it’s interesting. When you look at published studies that review pivotal trial data, they look at it very differently. Some of them make a mistake because you can’t count yeast infections as viral infections. Some of them make that mistake. Sure enough, when you look at registries of patients who have been infected with COVID-19, it looks as though patients on all the biologics, if anything, do better. They don’t do worse, and for methotrexate, that might not be the case, but they also might do better. That’s controversial.

Low-dose steroids at the outset are probably not great, but certainly late in the disease, steroids appear to be beneficial, so certainly, you can’t paint with 1 brush. The biologics appear to be good, not bad, in that setting, and I have managed to calm my patients down about that, and they’ve been accepting of the biologics.

Transcript Edited for Clarity