Paradigm Shifts in the Management of Plaque Psoriasis: Advanced Practice Provider Perspectives - Episode 9
IL-17 inhibitors and IL-12/23 inhibitors used in the treatment of plaque psoriasis.
Matthew Brunner, MHS, PA-C, DFAAPA: IL-17 inhibitors are 1 of the newer agents that are available. What’s interesting about both the TNF [tumor necrosis factor] inhibitors and the IL-17 inhibitors is that both of those classes initially have in common that they have strong data to support treatment of psoriatic arthritis. But the nice thing about the IL-17s is that in some ways, they have some more dosing flexibility. They don’t have to be dosed as often together for patients. The other thing about IL-17s is to appreciate and understand that those agents do have some other comorbidity concerns. If you have a patient with inflammatory bowel disease [IBS], you’ll want to be careful about using an IL-17 inhibitor because you could potentially exacerbate those underlying conditions. Then you have to be more concerned about fungal or candida infections in patients on IL-17s. These agents consist of secukinumab, ixekizumab, and then brodalumab. And brodalumab has a different niche. The way it attaches to the IL-17, it’s a receptor antagonist and it falls into its own special REMS [Risk Evaluation and Mitigation Strategy] program for a risk of depression and suicidality. It’s something that you want to have a careful conversation with the patient around that and screen them, and you have to be compliant with the REMS program if you’re going to use brodalumab for a patient. Having that discussion with the patient and helping to understand where the patients may have comorbidities or some concerns, sometimes that will steer the discussion in a certain direction for the patients. This leads us into talking about the IL-23s. We do have 1 agent that’s a combination IL-12/23. Do you want to tell us about that agent?
Lakshi Aldredge, MSN, ANP-BC, DCNP: We have the 1 agent, ustekinumab that is an IL-12/23 inhibitor, and it’s a medication that has been out for over a decade now, and can be very effective in both the skin, perhaps a little less effective in the joints, but it’s a medication that’s effective in the skin. It targets both IL-12 and IL-23. It has a double site. The dosing is also very convenient, especially in patients who may have busy lifestyles or even patients who don’t feel like they can give themselves the injection or, as I mentioned, they don’t have stable housing. It’s nice because they can come into the dermatology office and get the injections. The dosing for ustekinumab is week 0, then they come in 4 weeks later for a second injection, and then it’s 1 injection every 3 months thereafter. There are 2 doses with ustekinumab. For patients who are less than 90 kg, it’s 45 mg; for patients who are a little heavier, we have a higher dose of 90 mg. That’s really a nice option to have, weight-based dosing in this 1 class of biologic agent.
Matthew Brunner, MHS, PA-C, DFAAPA: Another unique part of ustekinumab that’s not approved in all the IL-23 agents is that it also has indication for psoriatic arthritis, which is a nice differentiator as well for those patients.
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Transcript edited for clarity.