Advances in the Management of Plaque Psoriasis - Episode 5
Mark Lebwohl, MD: Let’s move on to oral therapies. What are the oral therapies we have available, George?
George Han, MD, PhD: Some of the oral therapies we’ve covered: methotrexate, cyclosporine, acitretin, and of course apremilast. All of these still have some role in our usage. I think they are declining in my practice, as some of you mentioned. Cyclosporine we used to think of as the fastest-acting agent for psoriasis, but really a lot of our biologics nowadays have eclipsed that. So it’s really taken a more supplementary role, especially with all of the adverse effects that you can see with those medications. You have to worry about their kidneys with methotrexate, and the liver. Certainly, I find that in layering therapy, I still find a good use for acitretin.
Brad Glick, DO, MPH: Same here.
George Han, MD, PhD: And some of those other medications. Also with apremilast, it’s something that is a very popular medication, of course, right now. The efficacy is not spectacular overall, but I think in certain areas where you have scalp disease, palmar-plantar psoriasis, it punches a little higher than its weight class overall. I do find a role for that. I do find a role for additive therapy with apremilast as well.
Brad Glick, DO, MPH: Collaborative therapies I think are an important part of our future discussion. Clinical trials for psoriasis have been rather limited in that regard. Some of the atopic dermatitis trials, at the very least, allow for use of corticosteroids, which I think is unique and more real world. But for me a drug like apremilast, and for that matter even methotrexate, I use still fairly frequently as add-on therapy because you don’t always want to make that jump.
You may not want to make that jump or you have a patient who says, “No, I’m just not using my creams. I have a little bit left on my elbows and my knees, but I’m just not using my creams, and I moisturize every once in a while. What else can I do?” That’s my opportunity to be artistic because we can be so artistic with these drugs. And I go back, and I use older drugs all the time. Our systemic agents, particularly the biologics, are not necessarily perfect for palmar-plantar disease. I have many patients on biologic therapies, and I’ll add on acitretin, and I love that drug. I think it’s highly effective for palmar-plantar disease, at least in my camp.
Scott Gottlieb, MD: I would totally agree with that. I definitely use acitretin for palmar-plantar disease. One of the things that I’m excited about in terms of the future is the possibility of an oral agent with a better efficacy, and thankfully they’re working on like a TYK2 inhibitor and others that may yield a real nice bridge between a systemic agent, in terms of a biologic, and an oral agent that works better than what we currently have available.
George Han, MD, PhD: But I think that underlies the whole issue right now in that overall, our biologics are by and large much more effective than these oral agents, which is why I think the implication is we’re all using them more first-line. In the old days, there was this perception around biologics that these were unsafe medications, that you would get lymphoma and all these things. And especially with our newer agents, I find them much safer than the majority of our oral agents on the market.
Scott Gottlieb, MD: I think one of the greatest things about recent times is, generally speaking in medicine, as you increase efficacy of a drug, you probably lose out on safety. But here we’ve been increasing efficacy and increasing safety, and I think that’s been really a great thing.
Mark Lebwohl, MD: It’s funny, patients will come in and they hear an injection and they think, oh, it’s got to be more dangerous. But in fact, what I explain to them is pills are small molecules. They affect many different organs and sites in the body. Large injectable medications, which are antibodies or are similar to antibodies, target one tiny molecule. And you can give something that is so targeted, so designer made to not hurt the body, but it has to be given by injection.
Scott Gottlieb, MD: I like that one. I’m going to use that.
Mark Lebwohl, MD: I do say that regularly to patients. They generally buy into it. The other thing is overcoming the fear of injection. I say to patients, little kids do it. And actually, little kids with diabetes inject insulin often twice a day. We’re talking about now injections that we give as infrequently as every 3 months.
Brad Glick, DO, MPH: And a lot of the companies that produce these agents have designed devices, if you will, and some of the injections are certainly much less painful. Some of the autoinjectors are appreciated by our patients, as reviewed in many clinical studies. We’ve taken some of the excipients out and some of the agents like citric acid that burn a lot. And so our patients will actually tell us now that that wasn’t so bad, and I agree with that. I’m very much on board with this, the targeted nature of biologic therapies is a crucial educational point for our patients. And I think part of the theme that I’m hearing today is that we really are responsible to have to tell our patients about this, really educate them despite our limited time with them sometimes. But I think when they understand more about what these targeted agents can do, they’ll appreciate that a little bit of pain is worth a lot of little gain.
Transcript edited for clarity.