Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 9
Melodie S. Young, MSN, A/GNP-C: You mentioned infections, and you mentioned remote monitoring because it is 2020. With COVID-19 [coronavirus disease 2019] being what it is, let’s talk about that for the last couple of minutes that we have. Tell me some of the things related to managing your patients with psoriasis remotely, whether they are well controlled or you’re going to start something new. Talk about any other tips you might provide for your colleagues related to managing patients with psoriasis during COVID-19.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP:It’s been wonderful compared with some of the other conditions, such as skin cancers, moles, or something you want to biopsy. With psoriasis, once we have the diagnosis nailed down, it is about fostering that relationship, which can be done well via phone or with a telehealth visit like this. During this whole COVID-19 issue, I’ve done a lot of this, and I start out by asking them how they’re doing. Are they flaring? Are they having any reactions to their medications? What’s new?
If they’re a newer patient and they’re failing something or if I want to put them on something else, that may require some lab monitoring. For TNF [tumor necrosis factor]–alpha inhibitors, you want to check for TB [tuberculosis]. You want to check for hepatitis B.
Melodie S. Young, MSN, A/GNP-C: Liver enzymes.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: Yes, and we check for liver function. I’ll have the patient go to their local clinic area, where it’s convenient for them to have that done, and then I’ll get the results sent to me. I can then mail the patient the medication. If everything looks great, I’m going to tell them that I’ll call them back in 4 or 5 weeks to see how they’re doing and how they’re tolerating it.
For patients who are established, it’s lovely and super easy. Most of the time, if we get the patient on treatments that are so effective that they get clear and are able to maintain that clearance with very little flaring, it’s a 5- or 10-minute discussion. For my veterans [at the Veterans Affairs Portland Health Care System], I’ll ask, “How’s the fishing?” We talk about fishing or hunting for about 15 minutes, and then for the last 2 minutes, they’ll say, “My psoriasis is great. No flares. I love my medication. Don’t ever take it away from me.”
Melodie S. Young, MSN, A/GNP-C: “Give me my refills.”
Lakshi M. Aldredge, MSN, ANP-BC, DCNP:Right, exactly. Then that’s it. I sometimes don’t even talk with them for another year. That’s how effective these treatments are and how little hand holding and management there can sometimes be. At that point, I leave it up to the patients. When do you want to come in and see me? When do you want me to reach out to you again? It’s less about me trying to manage their disease, because their disease is managed. It is about ensuring that their overall health is well. I ask them, “Have you seen your primary care provider? Have you had all your age-appropriate cancer screenings? How’s your blood pressure?”
Melodie S. Young, MSN, A/GNP-C: Patients need to be getting those cancer screenings. You still have to see them once a year to do the skin cancer screenings.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP:Exactly. COVID-19 has been a challenge in some instances because we can’t have them come in to do those skin checks necessarily. But with the management of psoriasis, this is something we can do well over the phone or with a telehealth visit.
Melodie S. Young, MSN, A/GNP-C: A lot of times with my patients, I’ll say, “Now that telemedicine has been approved for psoriasis, if you’re stable and well controlled, I’ll see you once a year and do your skin check. We’ll do your TB test if needed. The other time of year we’re going to do a telemedicine visit. We’re just going to check in. I want to make sure you’re OK.”
I want to make sure they’re adhering to the treatment and not getting advice about what to do about their psoriasis medicines from someone else, particularly if someone is telling them to stop it. I’ve had that happen before. I’ll say, “Don’t ever stop your medicine without me.” If you need to postpone it for a couple of days until you talk to me, fine, but whoever prescribes your medicine is the person you should always talk to related to stopping it. Stopping and starting medicine can make it more difficult for you to get clear and get treated. Sometimes, with those quick call-ins to our nurses’ desk or to a biologic coordinator, we always say, “If you’re sick or if you have a fever, just hold your medicine, call in, and let me find out what’s going on.” We then decide whether we want to postpone their treatment.
Transcript Edited for Clarity