Reviewing Complex Cases: Psoriasis in Older Patients

In the first round of breakout sessions at the Horizons in Advanced Practice meeting in Las Vegas, Nevada, Omar Noor, MD, FAAD; Douglas DiRuggiero, DMSc, MHS, PA-C; and Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, focused on common challenges and innovations in treating plaque psoriasis and atopic dermatitis (AD). To foster collaboration and discussion around the cases, the meeting attendees were divided into 3 groups, with each Horizons chair moderating a session.

Case 1: Psoriasis in Older Patients

Noor presented a case of a man aged 70 years with a 20-year history of psoriasis. The patient was previously treated with adalimumab (Humira; AbbVie) and then switched to an IL-23 inhibitor, risankizumab (Skyrizi; AbbVie), due to a malignancy. While the patient was on risankizumab, he forgot to administer his self-injections at home. Additionally, he lost access to risankizumab when he turned 65 due to Medicare enrollment. Subsequently, the patient was lost to follow-up.

At the current time of presentation, the patient had 35% BSA coverage. His psoriasis was negatively impacting his quality of life. He liked to be active with his grandchildren but felt self-conscious about his scaling plaques. He was struggling with adherence to injectable therapeutics. Access to medications was a struggle through Medicare coverage.

Available Psoriasis Therapeutics

Noor first reviewed with attendees the current therapeutic landscape in psoriasis and what options are available for clinicians to prescribe:

• IL-23 inhibitors: tildrakizumab, risankizumab, guselkumab
• IL-12/-23 inhibitors: ustekinumab
• IL-17 inhibitors: bimekizumab, secukinumab, brodalumab, ixekizumab
• TNF-α inhibitors: certolizumab, etanercept, adalimumab, infliximab

Real-World Studies

To determine the best therapeutic option for this patient, Noor reviewed the efficacy of another IL-23 inhibitor, tildrakizumab (Ilumya; Sun Pharma), in examples of real-world studies. First, a study conducted by Burlando et al evaluated 26 patients with moderate to severe psoriasis who had a BSA of 10% or more, a Physician Global Assessment (PGA) score of 3 or higher, a Psoriasis Area and Severity Index (PASI) score of 12 or higher at baseline. In addition, 80.8% of the patients had received previous biologic therapy.

In Burlando’s study, 71% of patients(17/24) treated with tildrakizumab100mgat weeks 0 and 4, then every 12 weeks thereafter, achieved PASI 90 after 12 weeks. After 24 weeks, 91% (21/23) of patients achieved PASI 90. PASI 100 was reached by 67% (16/24) of patients treated with tildrakizumab after 12 weeks and 87% (20/23) after 24 weeks. Treatment with tildrakizumab improves PGA and Dermatology Life Quality Index(DLQI) scores.¹

A second study by Wei et al evaluated 30 patients with moderate to severe psoriasis, 40% of which had received previous biologic therapy. Overall, 60% (n= 18) of patients were biologic naive, and 6.7% (n= 2) had been treated with only apremilast (Otezla; Amgen). After 12 months of treatment with tildrakizumab at weeks 0 and 4, then every 12 weeks thereafter, 83% of biologic-naive patients achieved PASI 90 and 39% achieved PASI 100, respectively. For patients previously treated with biologics, 33% achieved PASI 90, and 25% achieved PASI 100 after 12 months.²

In a review by Costanzo et al of the phase 4 TRIBUTE study (NCT04229836), investigators assessed the efficacy and impact on health-related quality of life of tildrakizumab 100mg in adults with moderate to severe psoriasis who were naive to IL-23/Th17 pathway inhibitors in conditions similar to clinical practice. After 24 weeks, the proportion of patients achieving PASI scores of 3 or less, PASI 75, PASI 90, and DLQI 0/1 was 88.4%, 92.5%, 74.0%, and 70.4%, respectively. Overall, tildrakizumab demonstrated significant improvements in pruritus, pain, and sleep scores.³

Treatment Decision

In Noor’s presented case, after considering the patient’s treatment history and difficulty maintaining adherence, the clinician decided to initiate tildrakizumab 100mg subcutaneously at weeks 0 and 4, and every 12 weeks thereafter. Noor discussed with attendees the benefits of alternative care sites such as infusion centers, which can benefit Medicare patients with secondary insurance. Additionally, the buy-and-bill model may financially benefit physicians because better prices can be negotiated. However, it can also be burdensome to manage inventory and financial risk.

After receiving tildrakizumab, the patient felt comfortable and adhered to the scheduled dosing. He had no safety issues and had decreased BSA and reduced symptoms at 3 months.

References

1. Burlando M, Castelli R, Cozzani E, Parodi A. Treatment of moderate-to-severe plaque psoriasis with tildrakizumab in the real-life setting. Drugs Context. 2021;10:2021-2-6. doi:10.7573/dic.2021-2-6
2. Wei NW, Chi S, Lebwohl MG. Retrospective analysis in patients with moderate to severe plaque psoriasis treated with tildrakizumab: real-life clinical data. J Psoriasis Psoriatic Arthritis. 2022;7(2):55-59. doi:10.1177/24755303221077211
3. Costanzo A, Llamas-Velasco M, Fabbrocini G, et al. Tildrakizumab improves high burden skin symptoms, impaired sleep and quality of life of moderate-to-severe plaque psoriasis patients in conditions close to clinical practice. J Eur Acad Dermatol Venereol. 2023;37(10):2004-2015. doi:10.1111/jdv.19229