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Systemic Treatment Options in Plaque Psoriasis


Laura Bush, DMSc, PA-C, provides an overview of systemic treatment options for patients with plaque psoriasis, highlighting the follow-up process once treatment has been implemented.

Alexa Hetzel, MS, PA-C: Wonderful, so we’ve spent plenty of time with our female patient and after a detailed consultation with her, she’s opted for systemic treatment. Laura, what options does she have?

Laura Bush, DMSc, PA-C: So I would say methotrexate would be an option, although I can’t see her probably buying into it. I probably wouldn’t buy into that myself actually. Apremilast would be an option although she [probably] won’t like the side effects. I usually lay out the [adverse] effects of the headache, nausea, diarrhea and when I say the word diarrhea, that ends it usually. There’s the newer agent, deucravacitinib, which I love that we have a new bag of tricks. So with that agent, there [are fewer adverse] effects. There’s really not a whole lot of nausea and diarrhea associated. It’s pretty much a similar profile of adverse events, nothing stands out, and it has a little better efficacy so we might start on that. It is once a day pill. If you were going to offer her a biologic, you could do that.

I kind of like the oral agents as a gateway to a biologic sometimes. The nice thing about both of the oral agents we have is we have samples in the office so very often I’ll give a sample pack. If I need any labs or need to review their labs, I will give them a sample pack and say we have to run TB [tuberculosis] test; we’ll call you with the results and then you can start the pack. Or if I want to look at their renal function or their lipids, I’ll do that in process. But I would probably go with an oral agent on her. I think that would probably be a good sell to her. She has to buy in on it. I think we’ve already decided that a 50-year-old woman needs to decide what she wants to take. And I think that would be a reasonable option for a systemic.

Alexa Hetzel, MS, PA-C: So if you picked something like deucravacitinib, what would your follow up look like for her?

Laura Bush, DMSc, PA-C: I follow up usually at 1 to 2 months just to check in and make sure they’re not having any problems. Also to make sure they got the medicine, because sometimes they show back up and they [say] “I’m not any better.” I’ll ask, “Did you get the medicine?” [And the patient responds,“Well, no, I didn’t get it yet.” Or they didn’t get their pills in the mail, but they got the sample pack. So just to make sure everything’s good. And then I usually follow up somewhere [between] 4 to 6 months. Once they’re stable, I would go to 6 months to a year, depending on the patient.

Lakshi had said she likes to explain the whole we’re normalizing you [process], and it’s an opportunity to check in with your patient. Do a skin exam, make sure nothing’s popping up, make sure that they understand that they need to go to their primary care [provider] and take care of comorbid conditions. It’s just an opportunity for me to do that.

Alexa Hetzel, MS, PA-C: Yes. Will do you do any blood work when you have them follow up in 4 to 6 months?

Laura Bush, DMSc, PA-C: Not unless they need it. I will ask pointed questions and if I feel like, for instance, they had abnormal lipids and I want to help them with that. But usually I’ll send them to their primary care [physician] for that, so not usually.

Alexa Hetzel, MS, PA-C: Anybody else have anything different than what Laura said about follow up and blood work or anything like that?

Jennifer Conner, MPAS, PA-C: No, with deucravacitinib in the studies, there were no hematologic or serum chemistry changes, so we don’t have to do any follow-up blood work, which is reassuring.

Terry Faleye, MPAS, PA-C: Usually I’ll follow them up in about 8 weeks from the time that I saw them just to make sure that at least they’re actually on the medication. And then at the same time making sure that there’s nothing going on. But usually, yearly I like to follow patients just because biggest thing, especially coming from rheumatology is that I always ask the question about joints, because I do feel that things change over time and just reminding them. Is anything new, new with your joints, anything wrong going on in your hips and lower back? So just the element of knowing that we still have axial disease and different things in the back of our minds, especially when we have patients who have scalp involvement or certain areas where we know that we can definitely see a lot more potential higher risk of incidents of PsA [psoriatic arthritis]. But otherwise I find that I’m just monitoring. With deucravacitinib we’re not having to monitor them super heavy because there’s no true safety signals that’s alluding to that.

Alexa Hetzel, MS, PA-C: I get that question a lot about, do you check lipids again in 3 months, because technically it’s recommended. But I feel like when we manage our patients by checking their lipids once a month, and I’ve gotten as high as 800 mg/dL. I had a little bit of palpitations when that happened, but that is something that we’re scared. Not that I blew that off, but if somebody said 200-300 mg/dL, that’s fine. And really the difference is 10 mg/dL, it’s not that much. You could eat a cheeseburger the night before and it could be different. I think though for some of my newer colleagues, if you’re nervous, just check it. What harm is it to check it? If it makes you comfortable with it, then go ahead and do it.

Laura Bush, DMSc, PA-C: Or if the patient wants you to check it. So I’ll explain it to the patients and I’ll say if they haven’t had blood work, because a lot of times they can’t get into their primary care or they’ll say, “Can you check it?” Or if they’re nervous about it, they’ve read the PI or something like that. It depends on how savvy your patient is because sometimes they want it checked. But that’s not too often, honestly. I just use my good clinical judgment just as I would any other condition.

Transcript edited for clarity.

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