Emerging Treatment Options for the Management of Moderate to Severe Psoriasis - Episode 3
An expert dermatologist details the effect of the COVID-19 pandemic and other comorbidities on treatment selection for plaque psoriasis.
Jerry Bagel, MD, MS: The most important comorbidity to consider is psoriatic arthritis. Thirty percent of our patients have psoriatic arthritis, so you need to ask them about their symptoms of psoriatic arthritis every time you see them to see how they’re doing if they’re not evolving. That [psoriatic arthritis] is the most important one. The other comorbidity of many patients with psoriasis is obesity, and some biologics work better in people who are obese than others, so you have to consider that. Some may be a little safer, like the IL-23s [interleukin-23 inhibitors] might be safer in older individuals, so that would be something to consider. And as I mentioned before, Crohn's disease is a comorbidity of psoriasis, and obviously, with an IL-17, you would want to keep away from that in that case.
The 2 pathways, as I mentioned, are do you have psoriatic arthritis or don’t you have psoriatic arthritis. Because if you’re going to [treat] psoriatic arthritis, some of the TNF [tumor necrosis factor] inhibitors are really effective. Some of the IL-17s are really effective. If they don’t have psoriatic arthritis, even though Tremfya [guselkumab] and Skyrizi [risankizumab-rzaa] are FDA approved for psoriatic arthritis, I’d rather go with something that has fewer shots per year per patient because I think it’s easier for everybody. Also, I think right now, the IL-23 group is so safe that I’m leaning into that group even for psoriatic arthritis because I don’t have to worry as much about adverse events.
When COVID-19 first came on board, we were a little more concerned about TNFs because they might inhibit getting rid of viruses. So you might not have as much efficacy yourself to get rid of viruses. But as it turned out, I did a study on this in my office, we had 2000 people on biologics, and we had 2 people die with COVID-19. We had 500 people on phototherapy, and we had 5 people die of COVID-19. We started thinking that maybe the biologic agents would decrease the cytokine storm that people were getting from COVID-19 and decrease their morbidity and potentially mortality. It may have been the whole thought of, “Oh my god, these biologic agents are going to get us immunosuppressed and we’re not going to be able to fight COVID-19.” But really the reverse happened, and they didn’t get as severe of a case because their inflammation profile wasn’t as high.
What happened though in COVID-19, I would say, is a lot of patients stopped taking their drugs. Their psoriasis started to flare but not as quickly as I thought. I went back in my mind to Hurricane Sandy when people were disheveled, moved out of their houses, had to live with their in-laws, it was a mess, and they came in like 4 months later all flaring. This time it was like a year later before they were flaring because the drugs are better. They [the drugs] were keeping them under control longer than before. The IL-17s, the IL-23s were already in existence as opposed to just using the TNF inhibitors. It did [keep] some people from wanting to go on biologics because they were still concerned, and I had no reason to talk them out of it, I understood that. It was a fair option.
We found that there’s an increased frequency of heart attacks and strokes in people with moderate to severe psoriasis who are between the ages of 20 and 50. We’ve also seen that when we use biologic agents long enough, we can decrease the incidence of heart attacks and strokes by decreasing the amount of inflammation in the arteries. So we’re able to decrease inflammation not just in the skin, but also in the body.
Transcript edited for clarity.