Multidisciplinary Perspectives on the Management of Plaque Psoriasis - Episode 6
Mark Lebwohl, MD: The next question I want to ask and answer is about the standard of care for initial therapy. Here’s where you actually have treatments that we don’t use, so why don’t we start with you. What would your standard of care be for moderate to severe psoriatic arthritis?
Philip J. Mease, MD: Typically, when a person starts to have musculoskeletal aching and stiffness, 1 of the first things they’ll do is go to their shelf and get some ibuprofen or Aleve, which they have to treat their headache. If that’s helpful, great. They’ll use that for a bit. Eventually, if there is any degree of disease severity, they’ll bring it to the attention of a clinician, hopefully either their dermatologist, who would refer them to a rheumatologist, or their primary care doctor, who would refer them to a rheumatologist. Then we start introducing, at the base of the ladder, what we call conventional synthetic DMARDs [disease-modifying antirheumatic drugs], like methotrexate, but the care standards are gradually changing. There are certain situations where we actually might leapfrog to a biologic or target synthetic DMARDs in the new oral medications like apremilast or a JAK inhibitor.
It depends a lot on what they’ve tried already, what they have the capability of accepting at this stage when they’re being newly diagnosed, and then moving on to more significant therapies, especially with more disease.
Mark Lebwohl, MD: There’s a long list of things that dermatologists [have but don’t use]. Even though azulfidine, for example, has been studied for psoriasis, we never use it, and it did have efficacy. We never tell our patients to take NSAIDs [nonsteroidal anti-inflammatory drugs]. I will say, if someone has mild psoriatic arthritis, I can tell them to go to over-the-counter ibuprofen or naproxen and ask them to take that. The number of times a dermatologist would tell a patient to do that is incredibly small, whereas that’s part and parcel of what you do every day.
Philip J. Mease, MD: Yes.
Mark Lebwohl, MD: In terms of our initial therapy, if it’s moderate to severe, they’re usually beyond creams. Then they get into the realm where we discuss phototherapy, which you don’t have, of course. I would say, generally, oral therapies nowadays, with the exception of apremilast, have too many adverse effects or don’t work well enough. We often skip those, so methotrexate is not used often by dermatologists anymore.
Cyclosporine is hardly ever used. Acitretin doesn’t work well enough and has severe mucocutaneous adverse effects, hair loss, and things like that. We don’t use it that much, although for all those drugs I just mentioned, by people who see a lot of psoriasis, like me, I do occasionally have patients on them. But for patients with moderate to severe disease, if they’re going to come 3 times a week for phototherapy, God bless them. I wouldn’t, but I understand people wanting to avoid any “medicines.” Phototherapy is quite safe, but it is a pain in the neck. It’s 3 times a week for months.
We then go to biologics, and I have some patients on apremilast. It’s modestly effective, but it’s extremely safe. Patients are willing to take that. We’ll talk more about that later. But when it comes to biologic therapies, what an insurer will pay for has some impact on us, but we do try to fight for the best treatment for that particular patient, based on the comorbidities they have. Nowadays, the majority of my patients are started on a biologic therapy.
Interestingly, coming soon we have tofacitinib, which looks like it is going to have an excellent safety profile and is fairly effective. We’ll see what the FDA does in terms of monitoring that drug and monitoring requirements. Apremilast, as you know, does not have any monitoring requirements. But the safety that we’ve seen so far in clinical trials with tofacitinib make it a really promising drug. In the future, we have other JAK inhibitors coming as well, although 1 is specifically a tyrosine kinase inhibitor that has a novel part of the molecule the tofacitinib blocks. That’s why it doesn’t give us the adverse effects of JAK1, JAK2, and JAK3 inhibition. That may have a major impact.
We go primarily to the biologics. They’re very targeted and very focused, and that’s why they’re so safe and highly effective. We’ll talk about the mechanisms of each and what the future looks like for those patients. In terms of the role of topical therapy, which I was asked about, we do combine it with systemic therapy, and I would imagine that rheumatologists do as well. If you have somebody who achieves PASI [Psoriasis Area Severity Index score] 75 or PASI 90, that’s still 10% to 25% of the body surface area that might not be cleared. You might want to treat that with a topical in addition to whatever systemic agent you’re using. Topical therapy still has a major place, and of course for mild disease, topical therapy rules. We generally use topical therapy only for mild disease. Patients with limited disease are often reluctant to accept the systemic therapy.
Transcript Edited for Clarity