Taking the Path to Clearer Skin: Targeted Treatment Through IL-23 Inhibition for Plaque Psoriasis - Episode 7

Selecting IL-23 Inhibitors for Treating Plaque Psoriasis

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Benjamin Lockshin, MD, FAAD, comments on the higher efficacy and reliability of recent IL-17 and IL-23 inhibitors and how these factors into treatment selection for patients with plaque psoriasis.

Bruce Strober, MD, PhD, FAAD: So, Ben, this is a tougher question. How do you go about selecting among the various IL-23 inhibitors we have at our disposal?

Benjamin Lockshin, MD, FAAD: That’s a challenging question. I think we are fortunate to have 3 very good options. I think honestly to parse out the drugs, sometimes I choose dosing frequency. I think Q12 weeks vs Q8 weeks is sometimes a determining factor, especially if I’m bringing them into the office for their injections. And I personally think that the young male patient is the least [adherent]. I happen to live in that world. So many times, I’ll bring them in the office; 4 visits a year after the loading dose is nice. [I think about] tildrakizumab for patients that have Medicare, as that can be covered a little bit easier. But deciding between guselkumab and risankizumab is hard. And sometimes you’re a Coke [guy] and sometimes you’re a Pepsi guy, but I think that my ability to articulate the data from risankizumab and looking at head-to-head data against different MOAs [mechanisms of action] makes it an easier option for me to consider for my patients. And I always try to put myself in the patient’s shoes and say, “What would I go on if I were them?” And I would say 9 out of 10 times I am actually choosing risankizumab because of the dosing data, because of the other quality-of-life studies that we look at. Even that the most recent study looking against apremilast in terms of patient satisfaction surveys—which I think all of us know the patients are happier on a drug that is tolerated better that performs better—but having that data to draw on actually just allows me a little bit more information to push toward that patient to make them feel confident with that decision.

Bruce Strober, MD, PhD, FAAD: You know I would just add that if you’re a provider using biologics in particular IL-23s no matter what your favorite one is, you’re really doing a good thing. So I have my preferences, and I’m sure Jennifer has her preferences but in the end if you’re using these drugs you’re already at the right level because it’s kind of a first-world problem: Which is the best of these drugs that blocks IL-23? Well, it’s amazing we even have drugs that block IL-23 and any of these drugs can potentially improve patients’ quality of life and actually normalize them to a large extent.

Benjamin Lockshin, MD, FAAD: I think these newer medications are almost pushing me out of job security because I thought for a long time there was a true art to choosing what the appropriate medication is but these newer-generation biologics from the IL-17s to the IL-23s do provide such high levels of skin clearance—reliable skin clearance with good safety profiles—that you can almost pick into a bag and choose a good medication.

Bruce Strober, MD, PhD, FAAD: Well, you’re going to have a job then because they’ll tell you a lot of people a lot of patients are still amazed that you prescribe them risankizumab. All you might think is, well I learned how to use risankizumab and you’re a patient who should get risankizumab and that’s not any brilliant concept; it’s just that it is available and we use it. Nevertheless you have to be a provider who chooses to use these medicines and use them, as we said earlier, confidently and with an outlook that’s optimistic. So when you walk into the clinic room and you see that patient, you’re smiling and you don’t have this kind of pessimistic viewpoint on what the future is for them. It’s the opposite. You’re [able to say,] “I’m going to make you better.” And I think that’s what patients come to doctors to hear. [These patients are] obviously miserable with their psoriasis. So if you just use these medicines, you’re an important part of the process, even though it might seem so simple to you right now. And one thing I would add is I like to make this point. If you use drugs like risankizumab, you have really easy follow-up visits, right? So all of us are busy. We see large numbers of patients every day. And some of those patients are hard and challenging. But definitely the risankizumab follow-up visit is not one of them. And it’s kind of a built-in break in the action that allows us to quickly move forward with our day and feel good about ourselves. Let’s be frank. We went into medicine to help people. And if you can help a person, you definitely come out of the room feeling really positive about yourself. Do you have anything to add, Jennifer, to this conversation?

Jennifer Soung, MD: I think the follow-up is easy. And it’s to the point where my patients forget, and they’ll see me just once a year. And I’m totally fine with once a year as long as they come to that once-a-year [appointment]. And other times I leave it flexible to the patient because I don’t feel like there’s a lot I really truly need to monitor. But we do need to touch base that one time in there in case there are any changes in medication. I want to make sure they’ve seen their primary care doctor if any other new medications or comorbidities come up. And I love how you mentioned the integrative approach. I talk about it and emphasize it a lot because truly it is a systemic disease or can be a systemic disease and we want to treat the patient as a whole. I want them to be healthy in every aspect.

Bruce Strober, MD, PhD, FAAD: So that’s another great point. If you have a clear patient, they come back clear 6 months later or a year later, it’s still an opportunity because you have a little time to talk about, “Are you seeing your primary care physician? Are you having your overall health measured with blood work and counseling?” And then you can even mention how people with psoriasis are at increased risk for things like obesity, hypertension, dyslipidemia, diabetes, and those need to be managed, too, in order for them to lead a normal life span. And a lot of that information is very shocking to patients that they are at increased risk for some of these other comorbidities. But to me, that follow-up visit, which is easy on the skin side, is now dedicated to the overall health and especially young patients. They don’t have such a frequency of touch point with their PCPs [primary care providers], so you’re actually reinforcing things they need to hear going forward. So the ease of the follow-up visit still has benefits going beyond dermatology if you’re doing it right, and you’re not slowing your day down because it’s only another 25 seconds to bring up these issues.

Transcript is AI-generated and edited for clarity and readability.