Dermatologists often must weigh their desire for definitive data with the realities of caring for individual patients.
When it comes to closing practice gaps, says an expert, dermatologists often must weigh their desire for definitive data with the realities of caring for individual patients.
In other words, says Erik Stratman, M.D., "If you wait for perfect evidence to be available before making a change in your practice, you're never going to change your practice. There are rarely perfect studies," particularly in the field of dermatology. He is chairman and program director of the Department of Dermatology at Marshfield Clinic in Marshfield, Wisconsin.
Dr. Stratman defines a professional practice gap as the difference between what the professional is doing (current reality) versus what is achievable based on current professional knowledge. In dermatology, he adds, gauging such gaps proves extremely difficult because very few studies measure how the population of dermatologists actually practices. "That's what's so challenging – we don't know what most dermatologists are doing to diagnose and manage disease." To that end, he says, some of the best data on performance in practice come from audience-response questions like those used at the American Academy of Dermatology (AAD) Annual Meeting.
Furthermore, Dr. Stratman says that in dermatology, "We don't have a lot of guidelines telling us exactly what's the right way to practice. It's a rather empiric field." However, he says that to avoid indecision, "We all must use the best available evidence, which often isn’t perfect. And, we all have to realize, the best evidence today might not be best tomorrow. Think about psoriasis – what we thought about the pathophysiology 10 years ago is completely different than what we think about it today. We must be prepared to act today, but then evolve with new knowledge, testing and therapies."
Regarding psoriasis, says Dr. Stratman, one of the newer practice gaps involves whether to switch a patient who fails one TNF inhibitor to another TNF inhibitor. In this regard, an audience-response system revealed that 70% of Dr. Stratman's audience at AAD had experienced patients who did not respond to an initial TNF inhibitor. Furthermore, when faced with a patient who initially responded to a TNF inhibitor but stopped responding, 49% said they would switch to another TNF inhibitor; 26% would switch to another biologic class.
"Choosing an incorrect second therapy that also doesn't work can be costly, in terms of time, money and the patient experience," he says.
A prospective study of 5,423 patients with psoriasis showed that, among 105 who switched anti-TNF agents due to drug failure, 74% had reached Psoriasis Area Severity Index (PASI) 75.1 Patients most likely to succeed with the second TNF inhibitor agent included those who initially responded to the first TNF inhibitor, then lost response; and those who stopped the first TNF inhibitor due to intolerance or reactions rather than lack of efficacy, says Dr. Stratman. "Is it a huge number of patients in this group? No. But it's good enough for me to want to change what I do."
Nevertheless, he acknowledges that barriers to closing this gap include dermatologists' comfort zones and the influence of pharmaceutical companies and insurers. In clinical practice, adds Dr. Stratman, "we need to figure out ways for the average clinician to find quicker alternatives to PASI as an objective in-office measure." Electronic medical records that incorporate objective clinical images may be an easier option, he says.
The role of concomitant methotrexate therapy also remains somewhat unclear, says Dr. Stratman. More specifically, he asks that when giving a biologic drug to a patient who is tolerating but not responding well to methotrexate, should the patient continue on the methotrexate? In an 80-patient study, patients who responded best to adalimumab had the lowest level of anti-drug antibodies (ADAs); additionally, concomitant methotrexate seemed to reduce antibody formation.2
"This raises the question: should we extend the methotrexate therapy longer as a bridge to biologic use?" Based on this publication, "It's unclear what to do with methotrexate, and whether we should measure ADAs." These gaps exist because no guidelines specifically address these issues, and the ADA test only recently became commercially available, says Dr. Stratman. However, he says, this study and a handful of other small studies suggest that "maybe there is value in maintaining the methotrexate, at least for a while."
In the adalimumab study, he adds, most resistance developed in the first six months of use. Accordingly, he says that in his practice, "For patients tolerating methotrexate but in need of better disease control, I consider continuing the methotrexate at least for six months as I begin the TNF inhibitor, unless there's a contraindication. And if a patient isn't responding to a TNF inhibitor, dose escalation may not be the right choice if high-titer ADAs are already present. Before dose escalation, I’m now more likely to check for high-titer ADAs based on this study.” That might be a role for the ADA test, he says, although it costs around $500.
Similarly, says Dr. Stratman, dermatologists often struggle with the workup and treatment of urticarial dermatitis (UD). When asking AAD attendees how they work up this condition, he noted some practice gaps noted based on recent literature.
In a retrospective review of 146 patients referred to the Mayo Clinic based on a clinical diagnosis of UD, "Only half of them left with that same diagnosis.3 About half the time, they ended up with another discoverable disease," such as drug reactions and contact dermatitis.
Perhaps more importantly, says Dr. Stratman, 10% of study patients diagnosed with UD had malignancy known at the time of diagnosis or discovered within four months. "That to me seems like too significant a percentage to ignore. In my practice, I know I wasn’t taking a targeted malignancy review of systems with patients who present with UD. Now that's something I [do] differently."
For himself, adds Dr. Stratman, "this was a true knowledge gap. I had no idea that there may be a malignancy association with UD. To overcome the gap, I'm going to make UD more a diagnosis of exclusion. That means getting that thorough patient history, taking a skin biopsy and being quicker to perform DIF at the time of initial biopsy. I also now perform an autoimmune review of systems, as well as a contact dermatitis history, more quickly than I previously would have."
Dr. Stratman reports no relevant financial interests.
1. Piaserico S, Cazzaniga S, Chimenti S, et al. Efficacy of switching between tumor necrosis factor-alfa inhibitors in psoriasis: results from the Italian Psocare registry. J Am Acad Dermatol. 2014;70(2):257-62.e3.
2. Menting SP, Van lümig PP, De vries AC, et al. Extent and consequences of antibody formation against adalimumab in patients with psoriasis: one-year follow-up. JAMA Dermatol. 2014;150(2):130-6.
3. Hannon GR, Wetter DA, Gibson LE. Urticarial dermatitis: clinical features, diagnostic evaluation, and etiologic associations in a series of 146 patients at Mayo Clinic (2006-2012). J Am Acad Dermatol. 2014;70(2):263-8.