Expert Physician Assistant & Nurse Practitioner Insights on the Management of Plaque Psoriasis from Real-World Data - Episode 9
Jayme Heim, MSN, FNP-BC, and Matthew T. Reynolds, PA-C, discuss implications of real-world data on the use of IL-23 inhibitors in treatment of plaque psoriasis for older patients.
Jayme Heim, MSN, FNP-BC: There is real-world data regarding the use of IL [interleukin]-23 and those patients over 60 years of age, as well as patients who have a little bit higher BMI [body mass index], patients who have a BMI greater than 25. It’s demonstrated favorable and consistent safety outcomes. Can you comment on the importance of examining treatment outcomes in these patient populations?
Matthew T. Reynolds, PA-C: Absolutely. These patients are more typical psoriasis patients. We know that patients who have psoriasis have high rates of morbid obesity. We know that they have high BMIs, and we know that psoriasis as a whole can be bimodal in its transmission in the population. We know that young and older patients can get it, and we know that patients who are well into their 70s and 80s can develop psoriasis at any time. I think it’s important to have this data because it shows more of what we see in clinical practice. In clinical trials, certain patients are just not able to get into these studies. We don’t really get a good snapshot of who these people are or how they behave because we have specific BMI limitations, and we have specific age limit restrictions for our clinical trials that lead to the FDA approval of these great drugs. But now that we have this real-world data and the 5-year data to show what is really going on, I think it’s great to know that the older patients do just as well as the younger patients. We’re not seeing elevated events of MACE [major adverse cardiac events] events. We’re not seeing an increased risk of infection with increasing age. We’re not seeing blood clots or lab work abnormalities that you worry about with some of these older patients. I certainly still do a significant amount of blood work in my practice, as a rule. I feel like it’s just good medicine. We do screening labs, and then we do periodic labs. But for our patients who have high BMIs, we’re worried about overall risk for metabolic syndrome. There’s data now that shows that the IL-23 class does really well in these patients. These patients achieve the same level of PASI [Psoriasis Area and Severity Index] 75, PASI 90, and PASI 100 response rates. Our patients who are not in the metabolic syndrome class but do have high BMIs greater than or equal to 25, they also, thankfully, achieve the same levels of skin clearance rates. You’re not worried about dosing or giving extra medicine to these patients because we have all the data that shows that’s just not the normal, and that’s just not necessary. Most patients who go on these drugs who fit into these 2 categories, advanced age or high BMIs, typically respond similarly to our patients who are not in these categories. That, again, is just a testament to the molecules; it’s a testament to the binding site that has been chosen for these drugs. I think it’s great to have this data on hands and remember that when you look at these patients who walk into your practices.
Jayme Heim, MSN, FNP-BC: I agree with you, Matt. I did a real-world study, and we had quite a few patients who were over the age of 65 and patients who were in their 70s. There were no increased treatment adverse events related to infection or anything like that. Also, I’ve had patients in the study who were well over 300 pounds who responded very well to IL-23 medication. It’s great when you have real-world studies, especially phase 4 studies, where these are patients who you’ve seen right in your practice, they’re not limited in their inclusion exclusion, and they really are real-world patients. You’re seeing real-world results from them, and that’s extremely important.
Matthew T. Reynolds, PA-C: Absolutely.
Jayme Heim, MSN, FNP-BC: When we talk about the challenges we face in the management of older patients, you had mentioned earlier that having an in-office injection is not under the pharmacist benefit. The Medicare Part B and being able to come in and having some access because it’s more under the medical benefit, not under the pharmacist benefit; it has that J-code attached to it. What do you consider is the greatest challenge for those older patients suffering with plaque psoriasis?
Matthew T. Reynolds, PA-C: Thankfully, in our area, the challenges are just managing their other comorbid conditions. That’s why we choose this class of drugs for these patients. When we have these patients, especially when they need dosing every 3 months, we take that as an opportunity to treat all of their other stuff. Usually, these older patients have low grades of skin cancer, they have other rashes, they have other dermatitis that you’re treating, so it’s a great opportunity to follow your patients closely. Obviously, we do appreciate the fact that we can bill that under the Medicare Part B benefit. That’s great for us because we’re doing a lot of work for the patient, we’re making sure they get their drug, we’re purchasing it for them, we’re making sure it’s on site and ready to go for their appointment, we’re making sure they get it on time. I think that helps them to achieve those high levels of skin clearance rates because they are getting the highest level of care that they can get with these drugs. For our patients who are a little bit sicker, they’re a little bit in the advanced age, they have a lot of other comorbid conditions, the challenges are making sure that you don’t overload them, you don’t overtreat them. I think it’s easy to prescribe any of the new biologic agents for these patients. I like to be nice to these patients and make it as easy as possible, and I think that the every-3-months dosing for these older patients with the in-office administration, specifically, is a perfect paring for us in treating these psoriasis patients.
Jayme Heim, MSN, FNP-BC: I agree with you. The other thing that I thought about when you were talking is that, especially with patients who are a little more vulnerable just because of age or because of multiple comorbidities, we’re able to keep an eye on them. We monitor them, we know that they’re safe, and I think that that’s important, too.
Transcript edited for clarity