Practical Approaches to the Management of Plaque Psoriasis - Episode 14
Mark Lebwohl, MD: OK, let’s go to the third case, which is a 68-year-old man who has a severe case of plaque psoriasis. He has several risk factors for heart disease. First of all, age, and being male. And hypertension, hyperlipidemia, and insulin resistance. He noticed patches 2 weeks earlier, and they’ve worsened since then. His skin feels itchy and hot. The lesions first appeared in areas of low visibility, but before you knew it, it was on his arms and could be seen, and his trunk was covered.
So, first of all, what are your impressions of the patient? How would you select treatment options based on the comorbidities that were published in the AAD/NPF [American Academy of Dermatology/National Psoriasis Foundation] guidelines in 2020? Alan Menter, MD, was the first author. And it reviewed frontline and subsequent options. Leon, you want to take that one?
Leon Kircik, MD: Sure. I think this is your typical Medicare patient, right, a 68-year-old. He does have metabolic syndrome: obesity, hypertension, hyperlipidemia, insulin resistance—you name it, he’s got it all.
Now I don’t know if he’s got psoriatic arthritis or not. But let’s assume he doesn’t right now. I’m in private practice, I’m not in a university, so I have to be practical. And one of the things we always are thinking about is the insurance. One of the things that they want from us, even before we go to a TNF [tumor necrosis factor] alpha inhibitor, we have to show failure with either light [therapy] or methotrexate. I never do methotrexate. I put almost everybody in the light box for the first couple of weeks so that I can show that I did the light [therapy] and it didn’t work.
I would start with the light, and then I’m assuming that this person has a large body surface area, so it’s going to be; actually when I walk into a room, I don’t even think about mild, moderate severe disease. In my mind, I think this is either a topical patient or a systemic patient. That’s how I look at it.
I’m assuming this is going to be a systemic patient. So first he goes to the light box, and then a couple of weeks later I know it’s not going to work unless—and most Medicare patients, by the way, they like the light box because they are retired, they have nothing else to do. They come 2, 3 times a week. They hang out in my office. They talk to the girls; they have a cup of coffee. They don’t have to pay a co-pay. It’s actually almost like a social thing for them and they like it. And sometimes we get lucky, it works; sometimes it doesn’t. Most of the time it doesn’t.
Then this would be the ideal patient for, we talked about tildrakizumab, because he’s got medical benefit on the Medicare side, so I don’t have to deal with the pharmacy benefits. He does have metabolic syndrome, which we have proof that tildrakizumab, from the poster, patients with metabolic syndrome did as well as the ones without metabolic syndrome. I think that would be my first choice.
Mark Lebwohl, MD: Obese patients don’t do as well with most drugs. The poster with tildrakizumab makes the point that people with metabolic syndrome who are obese—which is part of metabolic syndrome—do just as well whether or not they have metabolic syndrome. And the point is that the IL-23 [interleukin-23] blockers, and in the case of that poster specifically, tildrakizumab is highly effective even in obese patients.
Leon Kircik, MD: Now, let’s assume that he has psoriatic arthritis. [Tildrakizumab] is not going to be my first choice. Probably I would go to an IL-17 drug, where I can kill two birds with one stone if I can get it approved. Most likely he’s not going to be approved because I have to go to a TNF alpha inhibitor.
And if I would go to a TNF-alpha inhibitor, probably I would pick certolizumab. And the reason that I would pick that, if you look at the long-term data for certolizumab, they [TNF-alpha inhibitors] have the best efficacy maintenance rate. They do have quite a bit of PASI [Psoriasis Area and Severity Index] 75 and 90 maintenance rates that the older TNF-alpha inhibitors don’t have. So that would be my choice.
Mark Lebwohl, MD: OK. James, would you handle that in a similar way, and Erin?
James Song, MD, FAAD: I agree absolutely with Leon. I think with the TNF inhibitors we have data that it may potentially help with cardiovascular morbidity and mortality, and one could question whether, these are claims-based studies, so maybe it’s not truly an effect and these are more of a healthy user effect, we call it. But still we have those data. And methotrexate too, at least for our patients with rheumatoid arthritis, it’s the same thing. It does seem to help with cardiovascular morbidity and mortality. So I would be OK with those. Certainly for some of my more obese patients, I prefer IL-17 or IL-23 if I have that choice, but I would agree with everything Leon said.
Erin Boh, MD, PhD, FAAD: When you look at this patient, he’s obese, he does have metabolic syndrome; I’m in total agreement with that, and insulin resistance. If you look at the long-term data for the anti-TNFs, you’ll see, again, infliximab is weight-based; you’re going to help him in that regard and he’ll get an active drug.
We know from data that the TNF drugs do improve insulin resistance, so you would improve possibly his diabetes. We know that the anti-TNFs are very effective in cardiovascular disease. If you look at the rheumatologic data, they show that patients who’ve had MIs [myocardial infarctions], if you put them on a TNF, you decrease the mortality, you decrease the incidence of second MIs with it. And the same thing is true in psoriatic patients on the TNF, that the anti-TNFs do decrease the risks of subsequent MIs. I think in this case the fact that he’s 68 [years old], he is probably on Medicare, at least in my state I have great difficulties getting any IL-17s or anything even in the office.
I think this patient would be a good candidate for infliximab, if you’re going to pick an anti-TNF. Granted, most derms [dermatologists] don’t have access to it in their own office, but there’s probably somebody in your community who could, and I think the patient would benefit. And overall, I think his metabolic syndrome may benefit, including atherosclerotic plaque disease, which has been shown with the TNFs to improve, as do the IL-17s, especially the As and the Fs, improve the atherosclerotic plaque disease. I think in general this would be one you could use infliximab for.
Transcript Edited for Clarity