Biologics bring hope, nonclinical hurdles

September 1, 2006

Missing follow-up appointments include what Ms. Coates calls the "out of sight, out of mind" phenomenon, which she says is less common in patients with psoriatic arthritis than those with psoriasis alone.

While biologic drugs have infused many psoriasis patients with newfound optimism, they also pose psychosocial challenges that can contribute to follow-up difficulties for doctors.

"From a clinical standpoint, doctors are putting patients on biologics, and people are generally responding really well. That's exciting, because for the first time in many of these patients' lives, they're experiencing clear skin, and they're able to not worry about their psoriasis for periods of time," says Kelly Coates, M.P.H., patient education and member services manager for the National Psoriasis Foundation.

RECALCITRANT DISEASE DILEMMAS

With patients' elation often comes an element of fear and uncertainty, she explains.

"Patients know the nature of the disease is unpredictable. Some have had spontaneous remissions in the past. That could be related to weather" or other variables, Ms. Coates elaborates.

However, she says such patients' disease almost inevitably recurs, and not knowing if and when this will occur over the course of biologic treatment can be stressful. Sometimes patients with clear skin don't believe they need to continue seeing their physicians, she adds.

"But in fact," Ms. Coates tells Dermatology Times, "such patients need to see their doctors to have blood levels taken or just to have their skin evaluated, because their doctors may recognize signs of (recurrence) before they do."

Other reasons for patients' missing follow-up appointments include what Ms. Coates calls the "out of sight, out of mind" phenomenon, which she says is less common in patients with psoriatic arthritis than those with psoriasis alone. Nevertheless, she says some patients seem to think, "If I don't see psoriasis, I don't want to have to think about it. And going to the doctor is going to make me think about it."

Ms. Coates says the above attitudes are especially risky when coupled with many biologics' intermittent dosing. In such cases, she explains, "Those doctors run the risk of not seeing their patient again," or of having patients return after lengthy absences feeling angry and frustrated about a recurrence.

To avoid these problems, Ms. Coates says, "Doctors are finding that they're having to invest resources and staff time to call patients" and get them back into the office. Fortunately, she says physicians can prevent such hassles by proactively educating the patient regarding the importance of regular checkups.

"Making that point clear early on can help reduce patients' willingness to skip out later down the line," Ms. Coates says.

LIVING WITH REMISSION

Even the most compliant patients don't always escape challenges, Ms. Coates notes.

"Many patients who have had the disease for decades don't know how to define themselves without it," she reveals. Like formerly obese patients after rapid weight loss, she says, "They're somewhat like turtles without a shell."

Therefore, she says some patients might need help changing the long-term patterns of social withdrawal to which their disease has contributed.

In this regard, Ms. Coates says, "Physicians are pursuing partnerships with mental health professionals on an as-needed basis, though this tends to be more popular at larger medical centers where this type of resource is available."

With the limited time that doctors typically spend with patients, Ms. Coates says, such counseling frequently falls by the wayside.

"If a dermatologist can broach the subject," she says, "that would be great." If not, she recommends referring the patient to the National Psoriasis Foundation.