Advances & Unmet Needs in the Management of Plaque Psoriasis – Expert Advanced Practice Provider Perspectives - Episode 12
Experts in dermatology discuss what patients to consider treating with deucravacitinib, as well as comment on the comparative safety and efficacy of other therapies.
Alexa Hetzel, MS, PA-C: So, Douglas, what patients would you consider for this treatment? Is there a specific subset of patients that would be contraindicated for this therapy that you see in your clinical practice?
Douglas DiRuggiero, DMSc, PA-C: The best way to answer that is make sure we understand what the indication is. What’s great about the indication for this medication is that it’s indicated for the treatment of moderate to severe psoriasis in adults who are candidates for systemic therapy or phototherapy. So, right away it separates itself from other small molecule tyrosine inhibitors that are in the alopecia areata space, or in the atopic dermatitis space. All of those indications are second-line therapies. This is right now, off the bat, telling you that this is a first-line therapy. By indications of the FDA, you don’t have to fail other DMARDs [disease-modifying antirheumatic drugs], other things, or other biologics in order to consider using this. I think that speaks to its safety. It speaks to its efficacy.
Now, even though the indication says that, it is recommended on the package insert that you don’t combine it with other potent immunosuppressants. So, right now, I think it’s going to be very difficult for us to try to combine this medication with biologics. I know there’s already talk about trying to do that. It would be used off-label and I don’t think insurance companies will cover it, but I’m sure there are trial centers and folks we have samples that we’re going to begin to hear about that.
So who should not be taking it? It’s the same questions you’ve got to go through and ask. Even though this medicine did not carry over the 5 black box warnings that the other JAK inhibitors had preceded it in other indications, remember this is the first JAK that indicated for treatment of moderate to severe psoriasis, or psoriasis at all, it still means you need to make sure that it’s the right medication for them. We still have to check QuantiFERON-Gold Plus or a TB [tuberculosis] test for these patients. So if you’re asking who should not go on this medication, well, if you find out that they have latent TB, they should not go on this medication till that TB is treated. If they’re on other potent immunosuppressants, If they’re on anti-organ rejection medications, that’s a potent anti-immunosuppressant, the FDA says this is not a medication for them. But these are small subsets of people. The majority of people who are healthy who don’t have significant comorbidities, who don’t have significant lab abnormalities, all these kind of things, are going to be candidates for this treatment. That’s what makes it kind of so exciting.
Remember what Darren [West, MPAS, PA-C] just alluded to. This is a first oral medication for the treatment of psoriasis that’s come out with PASI [psoriasis area and severity index]-90 and PASI-100 data in its label. So, it’s kind of hold on to your purse, really. We’ve got an oral medication that’s got PASI scores that are similar to early-generation biologics. They had 14% of patients at the primary collection end point time at 16 weeks that were at PASI-100, 30% of those patients are already at PASI-90. So, when you look at some of these numbers, they are very impressive and say that we’re getting patients fast relief and getting them on the track to clearance. So I’ve got to have a good reason not to use it. I don’t have to have someone talk me into using that. I have to have reasons not to use it and not to present it to patients as a very viable option.
Alexa Hetzel, MS, PA-C: I love your answer. Fantastic. So, Jayme, we just spent a lot of time talking about all of the other options available for treatment of patients with plaque psoriasis. Can you discuss your experience? Because we can’t really make a comparative since we don’t have studies, but can you talk about the comparative efficacy and safety that comes across all classes of medications that are out there?
Jayme M. Heim, MSN, FNP-BC: Well, not all classes. I think that it wouldn’t be fair to go ahead into all classes, not only due to the fact that we don’t have that data. When we talk about deucravacitinib, they do have a study against apremilast, and those are both small molecules. So, I think that really our discussion should focus on those 2 small molecules that we've studied in research. And when we see the comparison of efficacy for these 2 medications, there is definitely, as Darren alluded to, about a 30% difference between deucravacitinib compared to apremilast. So I think that that’s appropriate. We do not have any information in regards to other oral molecules, such as methotrexate, nor with biologic therapy.
The efficacy is there. They have their phase I, phase II, and phase III trials. Also, what Douglas had talked about, there’s not only PASI-75’s but there’s PASI-90’s and PASI-100’s with this medication. There’s strong, stout data with a PGA [Physician Global Assessment] of 0 to 1. Up to 70% of patients reaching a PGA of 0 to 1. So, there is some strong efficacy with this medication.
Transcript edited for clarity