Perspectives on the Management of Plaque Psoriasis - Episode 11
Panelists share which factors they use to determine optimal therapy in the moderate to severe plaque psoriasis setting.
Christopher G. Bunick, MD, PhD: Dr Torok, the last question in this segment comes to you. How do you approach patients with psoriasis? A big part of this discussion is to help other dermatologists, clinicians, and health care providers get an idea of how to take care of patients with psoriasis. We talked a little about smoking and obesity, but how does the presence of comorbidities influence your choice in biologics? How does the prior treatment with a biologic influence your choice? For example, if someone has failed a TNF [tumor necrosis factor]–alpha inhibitor, an IL-17 inhibitor, or an IL-23 inhibitor, how do you decide what to switch to?
Helen Torok, MD: I wish I had the spreadsheet that Mindera Health is working on for the RNA patch that’s coming. That would be lovely to know which biologic would clear up our patients. Right now you’re at the mercy of—if they have pitting of the nails, I wouldn’t go to an IL-17. If they have a comorbidity of Crohn disease, colitis, or inflammatory bowel, I’m not going to an IL-17, but I would go to the IL-12/23, ustekinumab, because that works well in Crohn disease. I have a lot of patients who are on that for their psoriasis and Crohn disease at my request. I will tell the GI [gastrointestinal] doctor, “Please get them off the TNF. Let’s put them on ustekinumab and work on the psoriasis and colitis at the same time.”
If they’ve been on biologics and have failed, I don’t have any problem going to another biologic, even in the same class. If they’ve been on secukinumab, I’ll go to ixekizumab. Because you’ll get a response from another drug in the same class even though they failed the first one. Or I’ll go to an IL-23. I like the quick action of the IL-17s, because as I tell my patients, “I want to clear you.” But I won’t go to an IL-17 if they have colitis or similar comorbidities. If they’re heavy, I’ll often dose them more. If I go to an IL-17, then sometimes I’ll dose them every 2 weeks. I have to beg the insurance company to approve that, and often they’ll approve it because patients are struggling and suffering. I’ll sometimes increase the dose rather than move to another class.
Transcript edited for clarity.