Evaluating Treatment Selection in Psoriasis

In "Evaluating Treatment Selection in Psoriasis," our panel delves into the decision making process for selecting the most appropriate biologic therapy for patients with moderate to severe plaque psoriasis, and the growing challenges posed by insurance driven treatment requirements and biosimilar step therapy.

The panel begins by outlining a practical framework for treatment selection, starting with identifying contraindications such as active inflammatory bowel disease, malignancy, or multiple sclerosis to narrow down viable options. From there, the discussion centers on categorizing patients as skin predominant, joint predominant, or both. For skin predominant disease, IL-23 and IL-17 inhibitors are both considered excellent options. For joint predominant disease, IL-17 inhibitors or occasionally TNF inhibitors are favored, with IL-17 inhibitors being the clear preference when axial disease is present. Patient preferences around dosing frequency and speed of response are also noted as important personalization factors.

The panel largely agrees that TNF inhibitors have been largely phased out of routine practice due to concerns around long term efficacy loss, laboratory monitoring requirements, and potential risks such as skin cancer in sun damaged patients, though a small subset of patients with predominantly joint disease may still respond best to this class.

The conversation then shifts to the impact of biosimilars and insurance formulary restrictions on clinical practice. The panel expresses measured acceptance of initiating biosimilar therapy when formulary access is limited, but raises concerns about forced switching between biosimilars, particularly given the immunogenicity risks and the potential for drug antibody formation that can reduce efficacy over time. The panel also questions whether biosimilar step therapy truly saves money in psoriasis when more effective therapies will likely be needed eventually, and highlights the lack of robust interchangeability data between biosimilars as an additional concern.

Our next episode, "Analyzing IL-23 Inhibitors in Psoriasis," further explores psoriasis highlighting the emerging pipeline of IL-23 targeted therapies, including a promising oral IL-23 receptor blocker and next generation TYK2 inhibitors, alongside a candid discussion of the real world adherence and efficacy considerations of oral versus injectable biologics.