Biologics and Advanced Therapies in the Management of Psoriatic Arthritis - Episode 14
Anthony M. Turkiewicz, MD: Steve, while I have you and we’re wrapping this session up, let’s talk about switching therapies. Under what circumstances in the dermatology world for psoriasis would you switch therapies? Obviously, lack of effectiveness or tolerance. And when you do switch, do you stay in the same class or do you switch to other classes?
Steven R. Feldman, MD, PhD: I switch when the patient feels like they’re not getting enough efficacy or if they’re having some adverse event, maybe if they don’t tolerate the treatment. It must be more than a mild lack of efficacy. They’ve got these treatment to target guidelines that say I should be getting patients clear. If the patient is happy on a drug that made them a lot better but didn’t get them quite close to clear, I’m not going to change their therapy. The patient must be quite bothered by their residual disease to make a change from a drug that helps and isn’t causing [adverse] effects to one that I don’t know if it’s going to work and it may cause a significant adverse effect. Once they’re already on something and it’s helping, and they’re doing OK on it, I have a reluctance to change therapies.
When I do change, it depends on whether it’s primary or secondary failure. If I put them on an IL-17 [interleukin-17] class and it doesn’t work at all, then I’m likely to switch them to an IL-23 blocking drug. If I put them on an IL-17 drug and it works great, and then a year or two later it stops working, I feel like an IL-17 works great for them until they develop an antibody against it, so I should go back to another IL-17 drug.
Anthony M. Turkiewicz, MD: Helpful. John, from the rheumatology standpoint, one of the most challenging consults I’ll get from medical dermatologists, who are, I won’t say risk averse or switch averse, which honestly I’m in the same boat, Steve, as you. I’m not a big fan of the flip-floppers, and you’ll see these patients who have been on 4 or 5 biologics in the course of a year, and I’m like, wow, what’s happening here? With that being said, John, when you get that consult from dermatology and they say, “Look, the skin is doing great, their gut’s not been an issue, they’re on this drug, and they had some joint complaints that didn’t seem to get better on this biologic. Here they are, take over.” Personally, I’m making sure that we’re dealing with psoriatic arthritis and not OA [osteoarthritis]. But tell me, John, give me an example of where you switch that particular patient?
John Tesser, MD: I would consider the following: If their skin is doing really well and the joints could use some help, I would actually consider adding a conventional DMARD [disease-modifying antirheumatic drug]. One of the interesting things that we’ve seen from the SEAM-PsA trial that was done with etanercept and methotrexate in combination or monotherapy of either one that Phil Mease, [MD,] authored, was that methotrexate is a good drug for psoriatic arthritis. We were seeing ACR [American College of Rheumatology] 20/50/70 criteria responses that are respectable and even responses for enthesitis and dactylitis and some nail changes.
I certainly would consider going back to methotrexate or even leflunomide or sulfasalazine unless there’s a lot of spondylitis involved, then that’s not going to work. But then it depends on how much articular disease and how much skin involvement was there. If there was a lot of joint disease, and the skin disease wasn’t that hard to control, and the patient is suffering a lot, it might require a change from whatever biologic is working for their skin, to a different agent, hoping that one can get control of both. It’s not an easy question, and it begs the question of how much joint disease, how much damage has occurred, how much more damage might the patient be at risk for developing?
Anthony M. Turkiewicz, MD: Very helpful. Never an easy visit, and again always letting the patient know. It’s tough when they’ve gotten success, such great success in one domain, to “switch” therapy.
Transcript Edited for Clarity