Mark G. Lebwohl, MD, and Joseph F. Merola, MD, MMSc, provide impressions to the case and take-home messages for dermatologists and rheumatologists treating psoriasis.
Mark G. Lebwohl, MD: What’s your impression of the case? What challenges does this patient pose?
Joseph F. Merola, MD, MMSc: I’ll try to keep this brief. I’m happy that we can have some dialogue. The skin activity is more straightforward. This patient has severe plaque psoriasis. We all agree on that… Let’s assume this patient indeed does have PsA [psoriatic arthritis]. Because of multiple failures in psoriatic arthritis, one has to consider, could there be an osteoarthritis component, a fibromyalgia component, another diagnosis that could be considered a failure of mechanism or drug. As a rheumatologist, I always think about that because when the patient comes with clear skin but uncontrolled joints, I’m worried about that. Here, it sounds like it’s failing because the skin is also not clear, so let’s assume that. Often, I like to hear what the specific experience was like with each class to decide. We just talked about that…. If this patient said, “I was perfectly controlled on my adalimumab for 5 years,” then perhaps it’s time to revisit infliximab plus some methotrexate [MTX]. Maybe that’s a good option.
We may get the benefit again of dose flexibility. This is an overweight patient. Mark said that his BMI was 32. Maybe that’s part of the story. What might be a really good option is infliximab, maybe a low dose of methotrexate. The patient may do really well in that context. I’d be careful with the methotrexate because they have diabetes. I don’t want to have a liver problem. With IL-17s, if the patient said they had an ideal response until it failed, maybe consider another. We have others in our back pocket: brodalumab, bimekizumab is coming, an IL-17A/F inhibitor with robust-looking psoriatic arthritis data. That could be an option. This patient hasn’t tried an IL-23. Would we consider a new mechanism? I certainly would. That makes a lot of sense. Would I consider a JAK inhibitor, such as upadacitinib? I might. This patient has cardiovascular comorbidities. This is pretty significant psoriasis. I’m not sure it will be sufficient, but would it help their psoriatic arthritis? It may come up a little lower on my list, but it may come up.
We talk about increased off-label dosing. Often patients do well with that. Mark and I have had that conversation many times. The patient who benefits from every-2-week dosing of their secukinumab or ixekizumab, their increased dose of adalimumab—all those are reasonable. I will quote 1 data point. There was a recent fascinating study done with secukinumab looking at patients who are overweight exactly like this patient. In fact, it supported our clinical suspicion that patients who are overweight do much better if you give them increased frequent dosing, meaning every-2-week dosing over every 4. That’s hard to get by insurance, but that’s something that many of us would like to see. There are many options. If someone held me down, I might pick infliximab because of the high BMI, which got a good response. Maybe a sprinkle of MTX if it was appropriate. Mark, I’ll stop talking. What would you do?
Mark G. Lebwohl, MD: I love your answer. I would say the same things. I’ll add a couple of things that weren’t said outright but that I know you meant. Both of us would be thrilled if the patient lost weight. Second, lisinopril has only a little negative impact on psoriasis. Because of that, whenever I have a patient like this, I’ll ask the general practitioner to switch them to an ARB [angiotensin-receptor blocker] like losartan instead of lisinopril. Third, when I get stuck with a headache patient like this—because of the weight, infliximab takes on some real meaning because you can up the dose. With some of the drugs—certolizumab pegol, adalimumab, you can give the dosing more frequently and get that higher dosing too. You mentioned bimekizumab, which is coming, and JAK inhibitors. Those are all options.
The combination therapy is for when I’m up against a wall and I don’t know what to do—you can add methotrexate, you can add apremilast. Unfortunately, the JAK inhibitors in the package insert say they shouldn’t be given with biologics. Biologics are much safer than methotrexate. To give a JAK inhibitor with the biologic is something that I hope, in the next few years, we’ll be able to prove is safe to give. The only reason it’s not in the package insert is they were never tested together. They allowed methotrexate, but they didn’t allow biologics. We should be able to overcome that.
Having said all that, this is a very instructive case. I want to thank the audience for putting up with us. Hopefully you learned something, and hopefully this will help you take better care of your patients.
Joseph F. Merola, MD, MMSc: Mark, it’s always a pleasure and honor to do these with you. Thank you.
Mark G. Lebwohl, MD: Thank you.
Transcript edited for clarity