'Pre-biologics' not necessarily prehistoric

June 1, 2005

Aat the recent annual meeting of the American Academy of Dermatology, there was a coronation of sorts. The biologic agents officially ascended to the status of treatment of choice for moderate-to-severe psoriasis. Several prominent dermatologists spoke on the subject and hailed these new agents as superior to old-fashioned remedies, which have now been dubbed "pre-biologics." Am I being too sensitive if I feel somewhat prehistoric when others label as pass? therapies that I use and upon which I routinely depend?

Different view I have a very different view of psoriasis therapy that I would like to share with you: The systemic agents that have been effective for many decades work just as well now as they did before this new era of medical care emerged a few years ago, with the advent of the biologics. Furthermore, we as physicians must make medical decisions based on risks, benefits and costs of therapy. Failure to take all of these issues into account will ultimately help to push the healthcare system over the cliff of affordability for most of this country's citizens. I have heard the argument made that we, as physicians, must place the well-being of our individual patients over cost considerations for the society as a whole. I disagree with this notion; in my opinion, we have almost a fiduciary responsibility to society as well as to our own patients.

Don't ignore reality To illustrate the point, an interesting poster was presented at the American Academy of Dermatology meeting. The authors calculated the lifetime financial outlay for various systemic therapies for psoriasis. They estimated that methotrexate would cost approximately $19,000 per lifetime. Total charges for alefacept would be approximately $320,000. We cannot ignore these realities when making medical judgments. The substitution of one excellent drug that costs 10 times what another effective medication costs will not automatically result in optimal care, especially if the definition of this ideal would include cost-conscious decision-making.

Methotrexate - This agent has been used for more than 40 years for psoriasis and psoriatic arthritis, and remains the gold standard against which all other treatments are measured. This drug has been dismissed as being too toxic for routine use. I strongly disagree with this notion. If patients are carefully selected to include only those without previous or present hepatic injury, and routine laboratory monitoring is used, methotrexate is a very safe medication. The rare idiosyncratic pulmonary toxicity should not dissuade one from administering this drug. At the doses that are used for psoriasis, bone marrow suppression is very unusual except in patients with renal insufficiency. This is an inexpensive agent that is among the best of all therapies for psoriasis, if one considers benefits, risks and costs of treatment. The monthly cost of this medication is $40 to $60.

Cyclosporine - This is one of the most effective and rapidly acting drugs available for severe psoriasis. It is an excellent therapy for the patient with an extreme, acute flare who needs a temporary respite while other treatments are contemplated or begun. The potential for renal toxicity and hypertension is real, but can be easily monitored by blood tests and regular blood pressure determinations. Another big advantage of cyclosporine is that most insurance carriers will approve of its use without major hassles. Cyclosporine is expensive, $400 to $600 per month, but as a drug used for a short time, perhaps up to six months, it can make a major impact on a severe acute flare of the disease.

Acitretin - This systemic retinoid is a good complementary drug to other therapies, particularly phototherapy. Pre-treating the patient for 10 to 14 days with acitretin before UVB phototherapy or photochemotherapy is begun will ultimately produce one of the most potent treatments for extensive plaque psoriasis. It is quite expensive - up to $1,000 per month - but if used as a short-term primer for phototherapy, the benefits can be very significant.