Paradigm Shifts in the Management of Plaque Psoriasis: Advanced Practice Provider Perspectives - Episode 11
Lakshi Aldredge, MSN, ANP-BC, DCNP, and Matthew Brunner, MHS, PA-C, DFAAPA share their personal experiences with using IL-23 inhibitors in treating patients with plaque psoriasis.
Matthew Brunner, MHS, PA-C, DFAAPA: We have 3 of these agents. We have tildrakizumab, which is dosed at weeks 0, 4, and 12; guselkumab, which is dosed at 0, 4, and 8 if I’m not mistaken; and then risankizumab, which is also dosed at weeks 0, 4, and 12. Can you tell me about your experience with each of these 3 agents?
Lakshi Aldredge, MSN, ANP-BC, DCNP: The first agent that came forward and was FDA approved was guselkumab. We were excited with that. I’ve had patients who’ve had both skin and joints significantly improved with guselkumab 100 mg. The dosing is week 0, 4 weeks, and then every 8 weeks thereafter. In the clinical studies, what we saw was that about 70% of patients with moderate to severe psoriasis had 90% improvement in their symptoms at week 16. With just 2 or 3 injections, they had 90% improvement in their symptoms. You mentioned those symptoms. It’s not just how their skin looks but that itch and that burning that are incredible.
Tildrakizumab is the second 1 that was on the market for an IL-23. What we’ve seen with that is about 63% of patients who have moderate to severe psoriasis see at least 75% improvement in their skin symptoms at just after 12 weeks, so 3 months of treatment. After 3 injections, patients are seeing significant improvement in their symptoms.
Risankizumab is the most recent lL-23 inhibitor that hasn’t been approved for the treatment of psoriasis. We saw high numbers: about 78% of patients with moderate to severe psoriasis who saw at least 90% improvement in their skin symptoms after just 12 weeks of treatment. The take-home point with these IL-23 inhibitors, what I tell them is they can expect really rapid improvement in their symptoms, and we expect them to get clear or near clear at least in 3 months’ worth of treatment. It’s rare that those patients don’t respond. Every now and then, you do get a patient who doesn’t respond as effectively. I have a very high-risk psoriasis clinic, so patients have recalcitrant disease with lots of comorbidities. There are a handful who don’t respond as well as we saw in the clinical trials. But in general, the efficacy is nice and the safety has been reflective of what we saw in the clinical trials and in the long-term safety data. Then again, the dosing has been convenient for them. The challenges with the IL-23 inhibitors and with any of the biologics is being able to get it to the patients who need it. Sometimes in underserved communities who may have challenges with insurance, it can be a challenge to get these medications into their hands. What’s been your experience with IL-23s, Matt?
Matthew Brunner, MHS, PA-C, DFAAPA: It’s interesting. When we first were going through the expansion from TNFs [tumor necrosis factor] into IL-17s and the IL-23s, it was this time of turmoil in dermatology because there were so many new agents. They really had a lot of new opportunity to help more patients. At this point, we had a lot of patients who were failing our TNFs and even failing ustekinumab. It was nice to have some options. I’d still really like to use my TNFs and my IL-17s in patients who have really aggressive psoriatic arthritis. For patients who may have milder to moderate or PSA [prostate-specific antigen], I will be a little quicker to reach from IL-23 agents just because the safety, as you mentioned, really does stand out as 1 of the differentiators in the class of drugs. It’s interesting, and I use all the agents, with the exception of infliximab, but each patient has their own reason why they’re on that agent. You’ll have patients who may have an injection site or reaction to 1 agent—they don’t tolerate that agent, so you’d have to move to a different 1. Or a patient who has recurrent abscesses or boils on 1 agent but can use a different 1 in the same class. It’s interesting to me that there’s a place for each of these drugs and all our patients, but I’m very comfortable with the IL-23 class. It’s my go-to starting class unless I have a reason why a patient may need 1 of the other agents. It’s something that stands out on its own.
But I love having all these agents. It’s amazing to be able to help patients who are in different places. As we see with all psoriasis treatments, even the biologics, there is wear-off effect. That’s unfortunate. Not every patient experiences that, but a good number of them were affected. We used to call that tachyphylaxis when we’re talking about topical therapy that patients would use for some time and it no longer seemed to be effective. But the same thing transfers into the small molecules or oral agents as well as the biologics. There’s this wear-off effect, and I don’t think it’s just about noncompliance. There is really something to it in terms of the immune system getting around the therapy.
Lakshi Aldredge, MSN, ANP-BC, DCNP:You’re absolutely right.
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Transcript edited for clarity.