Switching biologic treatments in dermatology

With so many new and effective therapy options available for psoriasis, dermatologists need to focus on evaluating and adjusting treatments to help all patients achieve clear or almost clear skin, says Abby S. Van Voorhees, M.D., reporting at the American Academy of Dermatology annual meeting in San Diego.

Dr. Van Voorhees, of Eastern Virginia Medical School in Norfolk, says that special attention may be needed for patients who are obese, or who have psoriatic arthritis, inflammatory bowel disease (IBD), or a fear of injections.

“It's critically important that we get more people clear,” she said. Dr. Van Voorhees chairs the National Psoriasis Foundation Medical Board, which in November 2016 published treatment targets for psoriasis.

As the number of options has grown, the key clinical question is no longer “What can I use?” but instead, “Where to start?” and then “Which one to use next?” “We have so many therapies now, so if one drug doesn’t work, we should consider trying to switch to another to see if we can optimize response,” she said.

While insurance considerations may dictate choices, physicians should consider comorbid diseases prior to selecting an initial treatment. For example, obesity can influence treatment choice. Treatment options that offer a weight-based dosing approach, or those that have demonstrated very high PASI 75 scores in clinical trials, may be appropriate in this case.

WHEN SYSTEMIC AGENTS FAIL

When one systemic agent fails, the next choice of therapy might depend upon the degree of response to initial therapy. For example, if a patient has any response to one tumor necrosis factor inhibitor such as etanercept, it could be reasonable to consider another agent in the class, such as adalimumab, she said.

“If we had a patient who totally failed the [etanercept] and they had no response whatsoever, then I'd be a little concerned that they wouldn't respond to another TNF inhibitor.”

The NPF’s treat-to-target recommendations suggests that target response be a body surface area of 1% or less.

When targets aren’t met, new discussions about treatment options that take into account clinical, socioeconomic and behavioral factors that could influence treatment outcomes. Switching treatments, dose escalation or combination therapies may also be considered. “These discussions also need to take into account a continual assessment of patient satisfaction,” she said.

FEAR OF INJECTIONS

Fear of injections may also guide treatment choice. For patients with this concern an oral therapy or one that requires fewer doses might be appropriate, but patient education to address fears associated with injections may be necessary.

In Self Injections 101, the NPF suggests that patients consider rotating injection sites from right to left to help reduce injection site soreness and pain and to avoid areas with active flare-ups.

The NPF recommends numbing the injection site to with an ice cube, and warming up the drug, either by removing it from the refrigerator about 30 minutes prior to injection or by placing it under the arm until it reaches room temperature.

DISCLOSURES

Dr. Van Voorhees reported disclosures related to AbbVie, Allergan, Inc., Celgene Corp., Derm Tech International, Dermira, Merck & Co., Inc., Novartis, and WebMD.

REFERENCES

"S040 - Systemic Therapies for Dermatologists: A Comprehensive Review and Update, Update for Psoriasis,"  Abby S. Van Voorhees, M.D., 1:30 p.m., Sunday, Feb. 18. American Academy of Dermatology 2018 annual meeting, San Diego.