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Role of Advanced Practice Providers in Plaque Psoriasis Treatment Follow-Up


Lakshi Aldredge, MSN, ANP-BC, comments on the role of nurse practitioners and physician assistants in plaque psoriasis treatment management. Jennifer Conner, MPAS, PA-C, reviews the long-term considerations with systemic therapy.

Alexa Hetzel, MS, PA-C: Lakshi, what’s the role of an NP [nurse practitioner] or PA [physician assistant] in treatment management and follow-up? I know I’ve heard some of my colleagues that maybe inherit patients once their supervising physician has started them on therapy or they start them on therapy and then they manage. And is there any difference [for follow-up] in terms of if you’re starting someone on deucravacitinib than, say, for a biologic?

Lakshi Aldredge, MSN, ANP-BC: No. I think that it should be viewed in exactly the same way. And I think that nurse practitioners and PAs are quite well suited to manage patients, even complex [patients with] psoriasis. So regardless of what treatment I have them on, if I initiate treatment, I’m going to see them back no later than 3 months, maybe sooner if it’s on an oral agent such as methotrexate to check blood work. But follow up should be fairly consistent regardless of the treatment. And then once they become stabilized, you may not see them for 6 months or maybe even once a year once they’re stable and doing really well and your comfort level with the patient is established.

But I think NPs and PAs are perfectly capable of managing all of these medications, whether it be a biologic, whether it be the newer oral agents, including deucravacitinib, as well as our topical treatment. Oftentimes we come from a background of perhaps primary care where we can also provide holistic care to patients and ask them about quality of life, their sleep, their nutrition, their happiness, their joy, and how psoriasis is affecting them. So I think that we’re very well suited to manage these patients long term, not only initiating therapy, but also managing them.

Alexa Hetzel, MS, PA-C: Awesome. So we all are used to somebody coming in [saying], “I’m going to do this, that’s fine, but how long do I have to be on it?” So Jennifer, what’s that conversation look like for a 23-year-old [woman] who’s like, “Is this forever? Is this the rest of my life?”

Jennifer Conner, MPAS, PA-C: So I take a line from one of my physicians I work with who has taken a special interest in psoriasis, and he’s brilliant, Scott Fretzin, [MD]. The answer he gives them is: You can stop this medication when you want your psoriasis to come back.

Alexa Hetzel, MS, PA-C: Very simple.

Jennifer Conner, MPAS, PA-C: Because this is a chronic lifelong condition. We may clear you, you may be completely clear, you may feel like a brand-new person with this medication, but the reality is you still have psoriasis [or] psoriatic disease. And so if this works for you, stay on it, don’t stop. Let’s keep going as long as we don’t have any adverse events or safety issues.

Alexa Hetzel, MS, PA-C: That is [the] nail on the head.

Terry Faleye, MPAS, PA-C: It is.

Alexa Hetzel, MS, PA-C: Anybody else have any great pearls that we can tell our patients?

Terry Faleye, MPAS, PA-C: I just tell my patients that it is a forever thing. It really is. And sometimes it is being honest with them because the truth of the matter is that it’s not going away. But I think the reassuring thing is the fact that we have stuff to make it feel like it’s going away. And so that way they are able to live the normal life that they had before they came into our office. Some [patients] believe you obviously, they [know] it’s forever. They go on medication and everything’s gone, and then they stop. And sometimes it is taking that stoppage, and they see everything come back, and they’re [surprised] it came back, [although] we talked about this.

Alexa Hetzel, MS, PA-C: That’s [when we get to] say I told you so.

Lakshi Aldredge, MSN, ANP-BC: The other thing, too, is I love the analogy, especially with young women: It’s like when do you want to go off your birth control pills?

Terry Faleye, MPAS, PA-C: When you want to be pregnant—that’s when you will.

Lakshi Aldredge, MSN, ANP-BC: You’re very consistent about taking that, this is no different. Again, using the analogy of blood pressure medication, no one’s just going to randomly stop taking that. And when I use that analogy of normalizing your body, this is normalizing your immune system. And we want to keep it normal. Stopping this medication means that we’re going to go back and put your body back in a state of being hyperreactive. We don’t want that. So this is your multivitamin for your body to remain normal.

Terry Faleye, MPAS, PA-C: I love that.

Alexa Hetzel, MS, PA-C: Also the concern that it might not work as well the next time. That’s always our big concern. That’s something that we worry about, but maybe they don’t understand so well either. You can just go back on your blood pressure medication or your birth control, but it’s different with these medicines. We don’t want to burn one if we don’t have to.

Jennifer Conner, MPAS, PA-C: That’s one of the things I tell them when they come in for follow-up. I say, “You’re doing really great now. Don’t go off of it because this could happen. If you do go off of it and we try to restart, it may not work as well, and then we’ve got to look for another class of drug.”

Transcript edited for clarity.

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