Variables that dermatologists should consider when selecting an appropriate biologic therapy to treat a patient with plaque psoriasis, and the importance of shared decision-making.
Andrew F. Alexis, MD, MPH: Let's shift gears to a more practical question, which I'm sure is a burning question in the minds of many in the audience. That is, well, we've got all of these great choices, how do you decide on which biologic to start with? I know that's a loaded question. I want to start with Dr Boh. How do you decide? What goes into your decision? What are the factors?
Erin E. Boh, MD, PhD, FAAD: Well, I'll tell you prefaced by saying that my state, Louisiana, does do step therapy. It does block a lot of things. A get-around is many of the drug companies give us drugs and they have good assistance programs. Patients can get drugs. If I'm able, I like to start with a biologic because I think safety-wise they're much better. Ease of administration, as Andy pointed out, it's easy to get a shot every 3 months. There's very little laboratory monitoring.
If I can get a biologic, I like to do that. How I choose which biologic is the key. The key to that for me is, what is the baggage? Meaning, what are the patient's comorbidities? All of these drugs are great, but it's not a one-stop for everybody, because every patient's psoriasis, even though psoriasis is classic and it looks like this, they're all different because they have different comorbidities. Patients who have arthritis and psoriasis, I may lean toward the TNFs, patients who have other comorbidities, maybe atherosclerotic disease or heart disease, again, I want to look at that and I make my choices more based on comorbidities. I also make selections based on what's easiest for the patient.
Some patients don't like needles. Other people don't want to take pills. Other people want to do their own shots. It's a conversation that I have with the patient. “What do you want to do?” I just direct them. If I have to, I oftentimes go to systemic therapies for a very short period because I can't get some of the biologics until patients have done methotrexate. I write them a prescription, they come back in a month, and I say, “Oh, you're not better, let's go to a biologic.” Then I've jumped through that hurdle. I can sometimes fight for the drugs.
Sometimes I do when people really need it. I think that's the key, you talking to the patient, and you and the patient deciding what's going to be best given the other diseases that are part of his or her package with the psoriasis. I think coverage is also important. Some insurance companies tell me, you must do an anti-TNF first. Well, I can bang my head against the wall and argue, but if they say I have to do a TNF and a TNF would fit, maybe I do that for a short time and say, “It doesn't work, or it works great but patients don't want to do it.” It's really what the patient and I come up with that is the best and safest for that individual.
Andrew F. Alexis, MD, MPH: Yes. Shared decision-making is very much an important aspect to this, too.