Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 11

Efficacy of IL-23 Inhibitors in Plaque Psoriasis

February 11, 2020

Douglas DiRuggiero, PA-C: The first IL-23 that got the approval in 2017 was Tremfya [guselkumab]. That’s what ushered us into this specific non—IL-12/IL-23 shared targeting, as we saw with Stelara [ustekinumab]. That’s the first 1 that came. It was really the first 1 that set its primary end point as a PASI [Psoriasis Area and Severity Index score of] 90, so it was raising the bar right off the bat. It set a primary end point of PASI 90, and it was hitting that primary end point with great success.

In the VOYAGE 1 and VOYAGE 2 trials, there’s a 70% and 73% PASI 90 at 16 weeks. That’s very impressive. Those numbers even go up as you look at the data at 28 weeks and 52 weeks.

The 1 thing I have liked about Tremfya since then is that other trials have come out—the NAVIGATE and ECLIPSE trials—and those trials are comparing it with Humira [adalimumab] and Stelara. So they have a lot of comparator data out there. It’s diverse data and real-world data looking at folks who have failed Stelara and then transitioned over, compared directly with Humira. I think they’ve got some good data with that IL-23 that show us that this works well and has raised the bar. We saw that bar continued with risankizumab, or Skyrizi, also coming out with PASI 90 and PASI 100 data. Weight didn’t seem to play a role in that product either. It’s nice to have these things that are so good at getting people all the way clear.

Melodie Young, MSN, RN, ANP-C: Yes, they’re phenomenal. There are very few diseases that have drugs available to treat them that can offer a patient—when you say a PASI 90, what you have to remember is it’s anywhere between. They’ve met at least a 90% improvement rate in their PASI score. It could be all the way up to 99%. So at least 90% improvement in three-quarters of the patients. And if you look at the end points at 16 weeks, don’t think that it’s going to be that many months before they begin to see improvement. It’s not uncommon for you to give them their first injection and then, 4 weeks later with the IL-23s, when they come back in for their second, you’re already seeing significant clearance and significant reduction in their itch factors.

Melissa Davis, PA-C: Symptoms, I was going to say.

Melodie Young, MSN, RN, ANP-C: Their symptoms. A lot of it will clear. You’ll see the central clearing beginning to develop. The minute they stop scratching, the Koebner effect will start to also play a role. Overall, people are just having a sense of more well-being, of just feeling better.

Melissa Davis, PA-C: When you were talking about the dosing of Stelara versus Tremfya earlier, Stelara was every 12 weeks. I had most patients come into the office. Also, because they had the prefilled syringe that spring-loaded, I gave a lot of feedback about that because I do think it’s a difficult device for patients to use—the prefilled, spring-loaded syringe.

Melodie Young, MSN, RN, ANP-C: It almost takes 2 thumbs.

Melissa Davis, PA-C: Yeah, and there are a couple of devices like that. But new with Tremfya is the 1 touch, 1 press, and it is a device that’s a little easier for patients who maybe have dexterity issues. But it is not spring-loaded. I like that, and I’m hoping some of the other agents that don’t have either a pen or a device have the same. I usually use it in the thigh on patients because it’s indicated for the thigh or the abdomen. You do have to put pressure on it. If you do that in the abdomen, it’s harder on patients. But on the thigh, I’ve…

Douglas DiRuggiero, PA-C: It’s got nice ergonomics too. It’s wider. It’s easier to hold, I think, for patients. That Tremfya injector is very nice.

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: I think those are all really important things that factor into our decisions. I use a lot of risankizumab and guselkumab, and I will tell you that patient lifestyle matters. Many travel. They don’t want to go back. They’ve been on ustekinumab. They do not want to go back to every 4 weeks. I have a lot of very educated patients. We look at these IL-23s, especially if they have severe plaque psoriasis, and we sit and discuss it. Some of them are a little nervous about the risk of inflammatory bowel disease with the IL-17s. But we also talk about, both of us, what the risk for psoriatic arthritis is. That plays into my decisions. Many do pick the IL-23s, and they are phenomenal. I make sure I tell those patients to give it a little more time. “You’re not going to see as rapid, as clear, initially as you might anticipate with some of the other products.” As long as they know and can anticipate that, they’re good. As long as they know whether there’s 1 injection, 2 injections, the whole pill concept goes out the window. They’re going to do whatever it takes to have that clear skin because they want that experience.

Melodie Young, MSN, RN, ANP-C: It cannot be more simple. It cannot be more simple than having a therapy that you could administer at home and only have to inject infrequently. And if you think of guselkumab as being a dose 6 times a year, and really, if you’re talking about 6 minutes 6 times a year…

Melissa Davis, PA-C: That’s just the first year, right? After that it’s 4 to 5 times a year, and that’s just with the loading dose.

Melodie Young, MSN, RN, ANP-C: Yeah. As you really begin to think about that, that’s beyond—again, 20 years ago when they did an assessment of how long patients were spending applying topical therapies, it was 35 to 36 minutes. The data said that people were spending a day applying topical therapies. One went on the scalp, 1 went in the gluteal cleft, another went on the elbows and knees; sometimes you had to occlude it. Then to drive over to get phototherapy 3 times a week for it to be effective—the drive over, the parking, going in, getting your treatment, and then you leave.

None of these had response rates of hitting 90% improvement in their PASI score, and the symptom relief with the speed at which we were seeing it, and with the ease.… And I’ll say that I need to see them a couple of times a year. Even if they’re going to be injecting at home, I still want to see them a couple of times a year.

Once a year, we’re going to reorder medicine and fill out all the paperwork that I need to make sure that I’m going to be able to get this drug approved and also to make sure that what they may not think is an issue might be something of concern. With the IL-17s, I love them. They’ve been very, very effective in people with psoriatic disease. But sometimes there are some yeast infections that people didn’t even realize were associated with being on an IL-17 treatment.

Transcript edited for clarity.