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Treating Comorbidities With Plaque Psoriasis


Lakshi Aldredge, MSN, ANP-BC, and Jennifer Conner, MPAS, PA-C, share treatment approaches to metabolic syndrome as a comorbidity with plaque psoriasis.

Alexa Hetzel, MS, PA-C: So we sent her to her primary care, and she was diagnosed with metabolic syndrome by her PCP [primary care provider]. Lakshi, how might this change your treatment approach for her now with this new comorbidity?

Lakshi Aldredge, MSN, ANP-BC: I think that that’s something we commonly see, at least I do in a lot of my patients, that they go on to develop metabolic disease. Especially in the United States, we tend to have more risk factors. Our diet isn’t great, we tend to be more sedentary, and that puts us at risk for my metabolic disease, which again puts us at risk for cardiovascular disease. This is going to be a game changer when I think about treatment. So topical treatments are adjunct therapy in this individual.

I need to put her on a systemic therapy that I know is going to decrease her overall inflammatory burden, which we know is going to impact not only her cardiovascular risk factors, but also the worsening of her metabolic disease. A lot of the oral agents that we have, as well as the biologic therapies, have data about reducing inflammatory burden. And we know that this is going to help influence her in decreasing those risk factors. So she’s definitely going to be on systemic therapy, possibly a biologic agent.

We don’t have a lot of data with deucravacitinib, and even apremilast necessarily with the decrease in other risk factors for metabolic disease and cardiovascular disease. We have some of that data with some of the biologic agents, specifically TNF [tumor necrosis factor]-α inhibitors, [Joel M. Gelfand’s MD, MSCE,]work at the University of Pennsylvania. But I think that we need to make sure that when we’re talking to our patients, especially those who have those risk factors, that we’re talking about the efficacy of systemic psoriasis medications on decreasing their risk for metabolic disease development. And then once they’ve been diagnosed, maybe helping to control the advancement of that and then also the progression on to cardiovascular disease.

Alexa Hetzel, MS, PA-C: Great. So we know with metabolic syndrome, it usually has high fasting-[glucose] rates that we look for. She also has diabetes. Jennifer, are there any potential interactions and considerations between plaque psoriasis treatments and diabetes treatments?

Jennifer Conner, MPAS, PA-C: [There are], particularly with some of the older medications, the oral medications, that we’d use. The newer biologic medications really don’t have any interactions with diabetes medications or insulin resistance or any issues there. But methotrexate, for instance, we have to think about patients with diabetes often will have impaired renal function. With impaired renal function, we could have impaired excretion of methotrexate and therefore methotrexate toxicity. Cyclosporine, we also worry about renal function there. I read something also with cyclosporine increasing insulin resistance.

With those older agents, I think we have a little bit of leverage, hopefully, with these type of patients if we have some pushback again in terms of access. I still see it once in a while, insurance companies will come back and say you need to try methotrexate first. With some of these data, we have information to help, hopefully, drive our decision to move forward with a biologic or these oral systemic medications.

Alexa Hetzel, MS, PA-C: I know sometimes the diagnosis isn’t a slam-dunk, like our last patient who every word was textbook, but some people come in on prednisone.

Jennifer Conner, MPAS, PA-C: All the time.

Alexa Hetzel, MS, PA-C: Laura, do you see that a lot too?

Laura Bush, DMSc, PA-C: I always say there must be an ATM outside urgent care and it has a prednisone button and an antibiotic button, and sometimes there’s a dual button. You insert your credit card, and you get both.

Jennifer Conner, MPAS, PA-C: Lotrisone [clotrimazole/betamethasone] also.

Alexa Hetzel, MS, PA-C: Lotrisone, and betamethasone.

Laura Bush, DMSc, PA-C: There’s a clotrimazole and betamethasone. I always tell patients when I diagnose them, you have psoriasis now, so don’t let anybody else give you oral steroids for this. It will have a holiday period, it will make it better initially, but it could make it much worse. And so I counsel them on that. But they come in sometimes [and say], “Oh, I’m on my third steroid round. Can you just give me some prednisone?” As a matter of fact, I had one this past week, they just called wanting prednisone and that’s what’s made him better in the past. So I have it all the time, I see that.

Alexa Hetzel, MS, PA-C: When you ask them, “What happens when you’re done?”—“It gets worse.”

Laura Bush, DMSc, PA-C: It gets worse. They always say that.

Alexa Hetzel, MS, PA-C: That’s a rollercoaster, and they don’t mind being on it, but that definitely could make her [glucose] levels go crazy.

Jennifer Conner, MPAS, PA-C: Absolutely. But they come in begging for another steroid shot.

Laura Bush, DMSc, PA-C: Just because they don’t understand. A lot of times patients just don’t understand the implications of a steroid. I always say it’s a feel-good medicine, but then it’s a hangover afterward. It doesn’t make your body feel good in the end.

Alexa Hetzel, MS, PA-C: Correct. That’s amazing. So then, Lakshi, how could the management of both conditions impact treatment [adherence]?

Lakshi Aldredge, MSN, ANP-BC: I think that it’s really important that just, again, that example that I used of, if you’re a diabetic, you’re not going to stop and start your insulin, your high blood pressure medicine, you’re not going to stop and start that. With psoriasis it’s same thing. So we want to get your body in a state of homeostasis again. Of course I don’t use that word. I talk about normalizing it.

We really want your body to be Switzerland. We want it to be nice and even-keeled. We want to decrease those risk factors for metabolic disease and cardiovascular disease. We want to decrease the risk of having psoriasis flares and worsening of joint pain or the development of joint symptoms. We’re keeping your body at a normal state of no inflammation or very low inflammation by taking your medications regularly, both for psoriasis and your other metabolic disease or high blood pressure, [etc].

Alexa Hetzel, MS, PA-C: Awesome. So Terry, how can we tell and educate this woman to grab the bull by the horns? How do we help her really express that she’s not happy with how she’s being treated at this point? Obviously, she’s there to see you now with her plaque psoriasis, but to really take control of her health care as a whole, what would you educate her on?

Terry Faleye, MPAS, PA-C: I think first off, I would probably educate her just largely and really probe her understanding of what psoriasis is. Because to this point, it’s a case where you can definitely tell that for her it’s just been in relation to her skin. She may have just been under the impression, I just don’t like it, and she’s covering it up and whether or not she’s seen her primary care doctor or whoever she’s seen in the past. But it’s really her understanding of the true implications of just living with the disease and just the internal effect that it has.

So I would start there, and just educating her on what psoriasis is and the effects that it has on all parts to her body and the importance of [how] we need to get on something relatively fast. Because we can tell from the data that the earlier that we start most patients on systemic therapy or even a more advanced therapy, the outlook for them is much different compared with those patients who start much later. So in this case, we’re already in some ways 10 years behind the 8-ball. It’s a case where we can’t undo what has already been done, but we can definitely catch up.

I think that in that situation just educating her and saying we have options. I would [definitely] put her on a systemic biologic agent knowing all the comorbidities that are going on. [Then] educating her and finding out: Is anything going on with your joints? Is this what’s going on in your body? I don’t want to lose the next 10 years that we have in the forefront.

Alexa Hetzel, MS, PA-C: For some patients, when I tell them it’s autoimmune, they’ll [say], “Oh, I also have thyroid issues.” I tell them, unfortunately it’s like Pokémon cards—you start to collect them all. The quicker we can stop the inflammation, the better we can control as a whole.

Terry Faleye, MPAS, PA-C: Correct.

Transcript edited for clarity.

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