Practice Perspectives on Optimal Patient Care in the Management of Psoriatic Arthritis - Episode 9
John Tesser, MD; Nehad Soloman, MD; and Jennifer Simpson, DNP, profile classes of interleukin inhibitors and the potential benefits for patients with psoriatic arthritis.
John Tesser, MD: Jen, what do you think about the guidelines advisement of recommending a TNF [tumor necrosis factor] over IL-17 or IL-23? That’s the ACR [American College of Rheumatology] guidelines, not so much the EULAR [European Alliance of Associations Against Rheumatism] guidelines. Do you think that’s really necessary? I would just add that for all these guidelines we’re talking about, the level of evidence for any of these advisements is very poor to a low degree of evidence. Keep that in mind when you hear us talking about them.
Jennifer Simpson, DNP: In the coming years, we’re probably going to be seeing that that’s going to change. We’re going to realize that the IL-23 and the IL-17 are going to target psoriatic disease a little more specifically than the TNFs do. ACR recommends TNF over those at this point, but I don’t think that’s going to stick around for too long. We can choose either freely, or maybe we should be choosing a IL-17 or a IL-23 over a TNF first, unless we have a very good reason not to. If it’s a patient, we have concerns about inflammatory bowel disease or uveitis as comorbidities or something else we have to be concerned about. But in general, is an IL-17, IL-23 going to be better suited for that disease state? We’re going to see this in the science and in the evidence that that’s probably going to be a better option for these patients.
John Tesser, MD: Those are good comments. I hasten to add that in both sets of guidelines, they do point out that if someone has a lot of psoriasis involvement, it might be appropriate to use an IL-17 over a TNF. The European guidelines will say an IL-17 or an IL-23. The American guidelines say an IL-17 over a TNF. I’m pretty sure the reason why TNFs continue to be first ranked is that there’s a larger and longer body of safety evidence of TNFs over IL-17s and certainly over IL-23 inhibitors, [so there’s an] edge for pushing something that we know is safe over a longer period of time. I’m in your camp. I’d say we’re going to make our decision based on the individual patient, the amount of disease, and where the disease is, and go for the best. We’ll get into the issue about step edits and such later. That’s where that’s going.
Nehad, there’s an interesting twist on 1 of the IL-23 inhibitors, guselkumab—Tremfya if you will—which got its label approval for fatigue because it prospectively used an instrument called the FACIT-F [Functional Assessment of Chronic Illness Therapy–Fatigue] score and statistically won that battle. How much does that matter for that drug? Does it necessarily distinguish that drug from others? More importantly, how much is fatigue important to patients with this disease?
Nehad Soloman, MD: I’m going to start in the reverse. For patients, fatigue is critical and we know fatigue is an integral part of many systemic inflammatory diseases, psoriatic arthritis being 1 of them. Unfortunately, many preceding therapies didn’t look at patient-reported outcomes as they did with Tremfya [guselkumab]. When you come later in the game, you get to amass some of the unmet study needs. Having this suggests that the drug in and of itself helps in this aspect, but it doesn’t negate or undo the therapeutic effects of other drugs. It’s just unknown. But we know from clinical experience anecdotally that when you get better control over the disease, many aspects—including fatigue—get better regardless of which therapy you’re using, as long as they’re meeting those improvements in outcomes measures. I’m sure we’ll get to that in a bit.
John Tesser, MD: We’re absolutely going to get to that. Jen, how important is the IL-23 inhibitor ustekinumab in your practice? Do you still use it? Did you previously use it more? Do you not use it? Where does that factor in?
Jennifer Simpson, DNP: We used to use ustekinumab more than we do now. Unfortunately, some of it is from a payer perspective and insurance changes. But still has utility for patients who have inflammatory bowel disease [IBD] like ulcerative colitis as well, and there may be overlap there. For a patient for whom we’re still able to use it in the office, or someone who needed to come in the office for injections vs taking it at home but maybe didn’t have great IV [intravenous] access, that would have more utility. We don’t use it as much as we used to, but it’s a good drug. It has its place, its niche, with patients with IBD.
This transcript has been edited for clarity.