Expert Physician Assistant & Nurse Practitioner Insights on the Management of Plaque Psoriasis from Real-World Data - Episode 8

Implications of Long-Term Data of IL-23 Inhibitors in Plaque Psoriasis

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Experts in psoriasis examine the implications of long-term data for IL-23 inhibitors, especially in patients who have not responded to initial treatment of plaque psoriasis.

Jayme Heim, MSN, FNP-BC: What are the implications of long-term data, especially in patients who may not have responded to initial treatment? What is that long-term data? What does that tell us about those patients who may not have responded to other medications?

Matthew T. Reynolds, PA-C: I think for us, those patients who didn’t respond to other medicines in the past, if they end up switching to the IL [interleukin]-23 class, they will achieve high skin scores, high skin clearance rates by the nature of the mechanism of the drug. Then over time, these patients will achieve skin clearance rates that they were never able to achieve on other mechanisms or other drugs that they’ve previously been put on. In my practice, I’ve had patients who have been on multiple therapies leading up to their time point of becoming my patient, and we’ve switched them to the IL-23 class, and we’ve finally hit the right button for them. But these patients who have been on other therapies for years and either had terrible adverse events, or terrible skin clearance rates, or have had injection site reactions, they finally switched to this class and get to the point where they don’t have any of those problems. They don’t have those adverse events, and they’re getting to the point where they’re finally clear. Then once again they stay on these drugs for years, they become one of your favorite patients.

Jayme Heim, MSN, FNP-BC: I agree. I think that a large amount of those patients who do respond to IL-23 continue to be responders to IL-23 over that longer course of time. Where before, we saw with other classes of medications, especially the TNF [tumor necrosis factor] inhibitors, that we were wondering, when was this going to stop? We also see some of those patients who did respond for an extremely long period of time, but most of those patients did have that problem with antibodies. So, we’re just not seeing that with the IL-23 class of medications, which is wonderful because our patients often want to know when they go on medication, how long is this medication going to work for me? Especially if they’ve been a patient who has been in another class of medication.

Matthew T. Reynolds, PA-C: We really don’t worry about neutralizing antibodies with this class, which is great. We know that they exist in other classes of drugs and specific ones, but it’s great to not have that as a problem.

Jayme Heim, MSN, FNP-BC: Now, like we talked about, not all patients will stay on therapy, especially because maybe they don’t respond. Not everybody responds to every medication. Even with the IL-23s, when you have a patient in your office, how do you know when to go ahead and change that patient if you don’t feel that they’re responding, or if they don’t feel they’re responding?

Matthew T. Reynolds, PA-C: That’s always hard because with certain patients, you know that they’re going to have higher skin scores, they’re going to have higher BMI [body mass index] rates, they’re going to have other things that are working against you. Some patients just have medications in their regimen that are essential that you cannot change, and you’re going to have to work around them. Personally, with the IL-23 class, I try to not switch patients before 3 months; I try to set expectations for most of my patients who we’re going to try to go to 6 months. I have some patients who are at 12 weeks or we’re going into 16 weeks, and we’re still not seeing a whole lot of efficacies. Certain patients just take a little bit longer time. We all know that with the IL-23 class, we’re not with a sprint drug, we’re with a marathon drug. The benefit of these drugs is more in the future versus in the immediate future. I try to counsel my patients and set expectations that I do expect them to start showing some signs of improvement by their first-month follow-up. But I expect them to have significant improvement by their 3-month follow-up. I’m not going to let my patients suffer. I am going to switch them when I do think that they need to be on a different class or we’re just not in the right direction. But generally, the 3- to 6-month window is where I typically fall as far as changing therapy or abandoning therapy.

Jayme Heim, MSN, FNP-BC: I think for me too is when a patient comes in and they’ll say, “I took my injection, I’m not seeing anything different.” Their plaques are starting to form again, and they’re just really not responding. For me, that really is a time point, if they’re just really not responding anymore, that we need to have that discussion on switching medication. Would you say that as an APP [advanced practice provider], do you think that patients pretty much want to stay on medication or want to switch, or it’s the other way around, where the APP says, “You know what, you’re really not doing well on this medication”? What has been your experience, and what do you usually do?

Matthew T. Reynolds, PA-C: There’s a wide range of patients who are out there, too. Some patients really expect to be totally clear after 1 shot, and they think that they’re going to just have this miraculous cure. Again, I like to set expectations, but I will tell the patient if I think that they’re not responding appropriately, if I truly feel that we’re not making the progress that I expect. When I treat patients with psoriasis with biologic therapy, I tell them, “I’m trying to hit a home run here. I’m trying to swing for the fences.” I think that’s what I expect, and I think that’s what you should expect, too. I will listen to them if they feel like they’re not doing well if they come in and tell me that they’re flaring significantly between injections and they’re miserable for 2-4 weeks before their next shot. I hear that. That tells me a lot. Thankfully, we have a lot of flexibility with dosing with this class because of the safety and the mechanism of action. I try to make it a team approach; I try to let the patient have their say, and then we provide the guidance and the medical reasoning that’s necessary to change or to alter treatment. I typically will be the first one to say, “Hey, this is not right.” I try to train everyone else who works with me to be the same way, to be an aggressive fighter for your patients, and to set those expectations clearly.

Transcript edited for clarity