Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 15

Treatment Guidance for Plaque Psoriasis: IL-23 Inhibitors

February 11, 2020

Melodie Young, MSN, RN, ANP-C: What are your warnings about patients on IL-23s? If you’re talking with a patient and you’ve decided they have moderate-to-severe plaque-type psoriasis—I think all my patients need to be clear. So I look at every single patient who walks in the door as a potential candidate for whatever therapy is going to take to get them clear, whether that’s a biologic or whatever. My goal is to get them to their maximum level of wellness with what I have available. The warnings are when people say, “What are the adverse effects for IL-23s,” for example. “Let’s make sure you don’t have tuberculosis.” I live and practice in Texas, and we have a fair amount of that. I would like to know if they have infections, because most of the data that come from these trials reveals that if there are infections they tend to show up by the first primary end point, so in the first few months. Then there seems to be less and less infections, less and less injection-site reactions, and things like that as we go.

What warnings do you give your patients? What adverse effects? When they’re asking about monitoring the drug, I’m really not monitoring the drug. I’m monitoring the disease. Psoriasis scares me. The biologics do not scare me. I know what I’m going to be looking for. All I know is I just need to get the patient as well as possible, and we have to make a choice on which therapy to use. Are there any things you say to a patient that you want to teach your colleagues, to make sure that they warn patients about or that they encourage them on?

Melissa Davis, PA-C: Yeah. With the IL-23s, specifically, I definitely screen them for history of serious infections or chronic infections and talk to them about that. That’s the main point I hit on. I tell them this is the main reason we’re drawing labs. The only lab we have to draw is a TB [tuberculosis] test, but I still draw a full panel on my patients because I do find that occasionally I find hepatitis in a patient who didn’t know they had it. Even though it’s not indicated, I still do that. So my biggest warning to them, I guess, even if it’s just to be aware of infections, and if they have an infection that we’re going to hold off on doing their injection when it’s time for that.

Douglas DiRuggiero, PA-C: How do you handle vaccinations?

Melissa Davis, PA-C: I ask them if they are up to date on all their vaccinations. If they need a live vaccination, I have them get that before we start their shot. Usually, when they’re in the office, unless I’m switching therapy, which we do sometimes, I don’t always have an up-to-date QuantiFERON-TB Gold. So if they are due for a zoster vaccination or are a candidate for it, I usually tell them, although now we have the 1 that is nonlive, so that’s nice. But this depends on what their insurance covers. For some of my patients, it’s the newer 1 that is covered. And for some, the older 1 is still the preference. But I tell them to go get those done prior to initiating therapy. Depending when they get it done, we’ll wait a couple of weeks after. But oftentimes, I think they’re up to date on their immunizations. Primary care does a pretty good job of that, at least in my patients.

Melodie Young, MSN, RN, ANP-C: It doesn’t mean that they can’t do a biologic. It’s just something that you have to consider. It’s pretty rare to have a patient for whom you have to alter your biologic plan because of something you find in the lab or something you worry about regarding their general health, as far as infections go. That’s another value, when people are coming in for their injections. If they’re sick, you can help figure it out. The whole chronic infections piece—we’ve all done primary care. That’s 1 of the things NPs [nurse practitioners], PAs [physician assistants], and physicians, actually, as well have all had exposure to primary care before we start with what we do. Sometimes when you find that they have a chronic bladder infection and you start talking about it, they have more of a pelvic floor dysfunction that’s making them have chronic bladder infections. It’s not the biologic doing it. You help them move toward the type of care, because many of them see you as their health care provider.

Margaret, are there any additional things you want to avoid or warn your patients about that Melissa hasn’t mentioned or Douglas hasn’t mentioned relating to starting an IL-23?

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: No, the infections are the most important thing. I would also throw in there that besides doing some basic screening, which is nice, I really focus on preventive screening. Many of these patients are at increased risk, and to spare the patient and the health care provider—that patient could have an underlying breast cancer, but they’ve put off their mammogram. They have a family history of colon cancer. I really, really, really—even though there are minimal screening guidelines, that is 1 thing with the IL-23s that I still uphold: getting their preventive and age-appropriate health screenings.

Douglas DiRuggiero, PA-C: You’re doing that for all medicines, not just IL-23s?

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Exactly, as well as just a good understanding that they’re at increased risk for infection.

Melissa Davis, PA-C: Really, on any of the systemic drugs—sorry to interrupt you—I do a screening panel, even with apremilast, even though it’s not indicated. I’m thinking, if this doesn’t work for them, I’m going to be moving on to another medication, and I would want them to already have that blood work done. Also, because of the comorbidities, to encourage them that they need to see their primary care doctor, etc.