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PP Treatment Efficacy


Tj Chao, MPAS, and Lauren Miller, MPAS, highlight treatment efficacy considerations for plaque psoriasis (PP).


Lauren Miller, MPAS, PA-C: Let’s talk about treatment efficacy and how we assess whether someone is on target with where we want them to be or where they want to be. What’s your treatment target, first of all?

TJ Chao, MPAS, PA-C: My treatment target is patient based. To be honest, it’s simple. If the patient is happy, then I’m happy. If I’m biased, I want every patient to be 100% clear. I’d love a BSA [body surface area] of 0, but that’s not always what’s important to patients. It’s a patient-specific situation.

Lauren Miller, MPAS, PA-C: If we talk about patient treatment goals and efficacy, depending on whether it’s a topical, a systemic, or a biologic, we’re going to need to give those areas or therapeutic options varying amounts of time before we make a decision as to whether something is effective. What’s your window—when we’re talking about topicals, for instance—before you say, “You should be at this point by now, and you’re not, so we need to go on to something else”?

TJ Chao, MPAS, PA-C: Honestly, 1 to 2 months is a good time frame as to how well the patients are going to do. If you’re talking about some of the newer agents, maybe you don’t see the full effect at that time frame, but you see an improvement with topical steroids. By that time, you may even see recurrence of disease after clearance. It’s completely variable.

Lauren Miller, MPAS, PA-C: I agree with the 1- to 2-month mark. Plus, we have to take into account if we’re talking about topical corticosteroids. We don’t want someone on that for long stretches of time. In regard to systemics or specifically biologics, obviously there are traditional systemics [such as] methotrexate and cyclosporine. I don’t use those much anymore. I’m more of a biologic user if I need something, but what would you say? They all have different end points if you look at their clinical trials. What would be your hard [stopping point] if you have somebody on a biologic and they’re not where you want them to be?

TJ Chao, MPAS, PA-C: My hard stop is about 4 or 5 months.

Lauren Miller, MPAS, PA-C: Four to 6 months [is mine].

TJ Chao, MPAS, PA-C: Exactly. The reality is that a patient’s timeline can be very different. Their timeline might be 2 months. If you have a patient who’s calling the practice trying to get in to see you, sending a lot of messages, you need to listen to that patient. Maybe you’d move that patient to another therapy faster because the disease is affecting their life in a negative way to the point where they feel that they can’t continue.

Lauren Miller, MPAS, PA-C: For all the options, based on their dosing schedules—specifically if we’re talking about biologics—it’s going to take some of those longer to see improvement. Obviously, we have to talk about expectations with patients, and we have to take that into account.

TJ Chao, MPAS, PA-C: Talking to patients about how the treatment is going to go [is important]. For example, if they’re using a topical and it’s the newer agents, then it’s going to be once a day. But if it’s a generic steroid, that’s going to be twice a day for 2 weeks at least. Some of the other agents are longer. Are you willing to do that? That’s not an easy feat, and it’s very difficult when a patient has to do that their entire life. You have to explain it in those terms. Once you talk to the patient about going on a systemic, you can make an effective decision about what they’re willing to do as far as dosing. Do they want to dose less frequently, or are they OK with dosing more frequently?

Lauren Miller, MPAS, PA-C: A lot of times patients—with topicals, specifically—think they should be able to put the topical therapy on and be clear in a week. When they stop it because maybe they’re better or clearer, the disease comes right back. And then they come in and say, “This doesn’t work.”

TJ Chao, MPAS, PA-C: Exactly.

Lauren Miller, MPAS, PA-C: You have to give them that expectation of what’s going to happen. You have to have that conversation with them.

Transcript edited for clarity.

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