Review of Current and Novel Treatment Pathways to Manage Plaque Psoriasis - Episode 8

Plaque Psoriasis: Contraindications of IL-23 Inhibitors

January 18, 2022

Dr Lebwohl explains the contraindications for IL-23 inhibitors when using them to treat plaque psoriasis.

Linda F. Stein Gold, MD: We’re talking about currently available therapy. Mark, talk to us about the IL-23 inhibitors. Is this the first-line drug for you?

Mark Lebwohl, MD:Oftentimes it’s a first-line drug. We have a nice choice. Sometimes a patient comes to me, and they’re somebody who doesn’t want to get injections frequently—let’s say it’s a person who travels a lot. They’re away a lot. They go to places where they don’t even have refrigeration. I remember the old days, when people institutionalized for health reasons or even for legal reasons were brought in shackles to the hospital ward to get their injections. Now they can get a shot 4 times a year, which can be administered here infrequently or by a health care professional there. We have big advantages over what we used to have.

The other thing is that the IL-23 blockers are given as infrequently as every 2 or 3 months. They hardly impact your life. If you have a kid going to college, does he want to keep syringes in a refrigerator where his friends go? With IL-23 blockers, they can show up every 2 or 3 months and be cleared. Until recently, if you gave Medicare patients an IL-23 blocker, all the drugs were covered by their medical benefit. They were given in the hospital or in the office. In recent months, Medicare has added risankizumab, guselkumab, and ustekinumab to the self-administered drug list, which means it’s part of your pharmacy benefit. There are big co-pays. Hidel was never tested for ethanol use. Fortunately, those patients can still get that 1 with a 0 co-pay. It’s part of your medical benefit. I often turn to that 1 for that reason, but I turned to the others for patients who can get the medication covered because they’re not on Medicare. The pharmaceutical companies have been wonderful about giving them discounts so that they don’t have to pay the co-pay. That’s worked out very well for patient care. Those scenarios make it easy for me to use IL-23 blockers. They’re also not contraindicated in malignancy.

Linda F. Stein Gold, MD: That’s an interesting and important point. Jerry, when a patient is in front of you, with not a significant disease, would you use IL-17 or an IL-23?

Jerry Bagel, MD, MS:That’s a tough 1. It will be 1 of them. It will depend on psoriatic arthritis. Let’s assume it doesn’t because you asked just for psoriasis. If they’re bad—let’s say they’re 40% body surface area—I’m going with an IL-17 because I want to make them better quicker.

Linda F. Stein Gold, MD: Does it change if they have arthritis?

Jerry Bagel, MD, MS:No, I liked IL-17 for that too. That will go along with it. My split is between the IL-17s and the IL-23s. I’m curious: do people differentiate among the IL-17s? Leon, you mentioned IL-17s as a class. Do you see a difference between secukinumab or ixekizumab?

Leon H. Kircik, MD:My hands are tied. Whatever the insurance pays, I’ll take it.

Jerry Bagel, MD, MS:Right now, they’re not paying for ixekizumab, so that’s a tough 1. At least in my neck of the woods.

Leon H. Kircik, MD:Depends on where you are. It’s all local.

Jerry Bagel, MD, MS:Let’s get away from that for a second. In reality, do you feel that 1 works better than the other? Do you like 1 more than the other? Do you see your patients respond better to 1 than the other?

Mark Lebwohl, MD:It’s fascinating because there are 2 factors that differentiate them. Ixekizumab works better, but as you know secukinumab is going to get approval for every-2-week dosing, which works better than ixekizumab. They’re solving that problem. Right now, ixekizumab hurts more, but they’re changing their formulations so that they take away that pain. The beneficiary in the end is the patient. We can have drugs that work better and drugs that hurt less. Patients benefit from both.

Linda F. Stein Gold, MD: Mark, which would you choose, IL-17 or IL-23? Or does it depend?

Mark Lebwohl, MD:Exactly what Jerry said. If it’s psoriatic arthritis, they get an IL-17. We have a large Crohn [disease] population. They obviously would get IL-23 blocker. Then I send them out. Do they need to get better quickly? If they are very sick, like Jerry, I want them to get better quickly, so I’ll give them an IL-17. If they’re not that sick and they want fewer injections, I’ll give them an IL-23.

Linda F. Stein Gold, MD: Leon, do you have a different perspective or similar?

Leon H. Kircik, MD:No, It’s very similar. If a 28-year-old girl comes and she’s going to her honeymoon, and she wants to be clear in 2 weeks, then it’s IL-17. There’s no question in mind.

Linda F. Stein Gold, MD: Mark, you touched on this: somebody who has a history of cancer. You’ll go with IL-23?

Mark Lebwohl, MD:Look at the package inserts. The IL-17s and IL-23 do not mention the words cancer or malignancy. They’re safe to use. There are a lot of data supporting their use. We’re building registry data, which show no increase. We just published an article showing a hazard ratio for getting cancer on secukinumab vs not being on it. It was 0.99, meaning a 1% reduction. We entered this hoping that we would show a real reduction because in animal models, when you block IL-23 or IL-17, you see a reduction in cancers. But we didn’t in that small—not that small—group of patients on secukinumab. The bottom line is that there’s no increase.

Linda F. Stein Gold, MD: That’s huge because this is an issue that does come up. Many people have a history of cancer. The clinical trials usually exclude those patients. It’s important to have some options for all our patients with psoriasis. This was a wonderful discussion of the state of where we are in psoriasis therapy.

Thank you for that great conversation. Thank you, Mark, Jerry, and Leon for this rich and informative discussion. Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box.

This transcript has been edited for clarity.