Changing Treatment Approaches in the Management of Plaque Psoriasis - Episode 8

Treatment Considerations for Patients With Biologics

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A panel of experts provides an overview of factors to consider when selecting therapy for patients with plaque psoriasis, including comorbidities, patient preference, and physician education.

Brad Glick, DO, MPH: We talked a little bit about comorbidities and influence on our therapeutic selection. I would ask this because I know, Erin, you touched a lot on, for instance, inflammatory bowel disease, and the potential impact of choosing a drug like interleukin-17 blockers, which would be contraindicated. Dr Han said, TNF [tumor necrosis factor] inhibitors covering the gut commonly change the course of the skin. Looking at our patients, what role does patient preference play when choosing biologic therapies? George, what is your comment there? What is their positioning in the therapeutic selection, if any?

George Han, MD, PhD: I think we have to be cognizant of the fact that if you do not explain it well, and if you are not on board, what happens is, you write the prescription, and the patient does not get on the medicine. That happens a lot, so I think it is important that we have that open conversation. When we are talking about someone who is ready for an injection, or they just want to still try topicals or orals, I think the most important part is to get that relationship, to explain the benefits of each one, and then guide them along the path. I think we are beyond the days of medicine where we say, “This is good for you; this is what you should be on.” It is a conversation, and I think it goes both ways. I mentioned some patients who do not have the largest body surface area, but they just want to be on a medicine that makes them forget they have psoriasis, aside from an injection every 3 months. Then on the other side, we have patients who are very severe who are just very reticent, so you say, instead of pushing them, “We will work with you. Let’s try with the topicals, but let’s reevaluate it. Let’s make sure we talk about it, and let’s make sure we talk about what your concerns and hang ups are.” Then you go to the other end—I haven’t had this happen too much, thankfully—like somebody comes in and says, “I want the Cyndi Lauper drug [Cosentyx].” Well, you have to have a better reason, and if you want the Cyndi Lauper drug, and you have IBD [irritable bowel disease], I am sorry, but you are not getting the Cyndi Lauper drug. We try to work with them to a certain extent.

Brad Glick, DO, MPH: Erin, any additions there in terms of patient preference, engaging our patients as to what their options are?

Erin Boh, MD, PhD, FAAD: I think George said it in a word, it is education. I think if the patient comes in, and they have whatever their notion is, that is great. You have to listen to them, present the data, and then you both move forward, because as we treat these patients—I tell everybody, “I don’t have this disease. I can give you something that makes it better, but you have to be on board, too.” This is a commitment that we make with our patients, that we have this relationship, sometimes more than a marriage. You have to listen to what they want. You do not give them what they want, they are like children, but if you talk to them, you give them good, sound reasoning, and you make a joint decision, then I think patients are going to be compliant. I think it is about education. If we spend a few minutes upfront talking to people and telling them about the risks and the benefits of treatment, and the fears they may have, you get rid of that, and then everybody moves forward. Sometimes, you do have to revisit, because people are reticent to jump into the water, and I get that. But we do need to educate all along, and if we do not, you are not going to have a compliant patient.

Neal Bhatia, MD: Erin, are you talking about patients, or are you talking about dermatologists? You can make that same argument.

Erin Boh, MD, PhD, FAAD: Actually, Neal, I think that is a very good point; it is both. We have to keep telling our colleagues that these medicines are safe. They are not easy to get, but if you get a process going, one that works in your office, you can get the drugs, and I think teaching physicians to get over those hurdles is just as important as teaching patients that the drugs are safe.

Neal Bhatia, MD: Absolutely.

Erin Boh, MD, PhD, FAAD: That is a big job for us.

Neal Bhatia, MD: It is, and you are right, because if the dermatologists are not buying into it, the patients will not either.

Erin Boh, MD, PhD, FAAD: They will not, and I have had so many people come to me, and they say, “Well, my dermatologist says there is nothing that you can do but steroids.” And that is the one time that I say, “Thank goodness for commercials.” I do not like direct-to-consumer marketing, but sometimes, it helps. Maybe that is not the right drug for the patient, and that is where your talk comes in, but I do think we need to educate both.

Neal Bhatia, MD: Yes. Or there is the concern that I have seen too many times, when I hear about physicians’ assistants and nurse practitioners saying, “Well, I want to write [prescriptions for] some of these drugs, but my physician who is working with me won’t let me.” I find that always very interesting.

Erin Boh, MD, PhD, FAAD: That is. They probably go to the talks. 

Brad Glick, DO, MPH: If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox. Thank you, everyone. Have a great evening.

Transcript edited for clarity.