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Treatment Selection for Plaque Psoriasis

Video

Drs Mark G. Lebwohl and Alice B. Gottlieb discuss how to select treatment for plaque psoriasis based on mechanism of action.

Mark G. Lebwohl, MD: Let me ask another question, which is we have so many mechanisms available to treat psoriatic disease. We have TNF [tumor necrosis factor] blockade, we have lymphocyte activation, replication of keratinocytes, and now we have IL [interleukin]-17 blockers and IL-23 blockers. How do you go about finding the right approach for each patient? Why would you select 1 class or mechanism over another?

Alice B. Gottlieb, MD, PhD: Here is my algorithm in the rough outline. When I see a patient with psoriasis, the first question I need to know is do they have psoriatic arthritis? Because it matters in terms of treatment choice. The other question I need to do is inflammatory bowel disease. Why? Because it matters. Let’s take the case of psoriatic arthritis. There are now for both ixekizumab and secukinumab comparator studies with adalimumab, a TNF blocker. In terms of the joints, the results are equally good. Whether one uses 1 of these IL-17 blockers or adalimumab. However, the skin response is better with either IL-17 blocker than with adalimumab. If I have a patient where I want to make sure I’m covering psoriatic arthritis well, which for me is almost all patients, but for many patients I’m going to pick an IL-17 blocker. Another reason why I might pick it is that if I have a patient who wants to clear quickly. And for speed, IL-17 blockers own that right now. They’re extremely fast.

Now let’s ask about somebody who has Crohn’s disease or ulcerative colitis. In this case, I probably prefer not to use an IL-17 blocker. And then IL-23 blockers, which 1 of them is now approved for inflammatory bowel disease as is 1 of the JAK [Janus kinase] inhibitors. Those move up on the list when I have somebody with inflammatory bowel disease. What we don’t have in IBD yet is a comparator study of an IL-23 blocker with a TNF blocker. We don’t have that yet. I’ll point out that that would be important to do. If I have somebody who has psoriasis and is either not concerned of psoriatic arthritis or I have a low suspicion they’ll ever get it, then the convenience of an IL-23 blocker with very infrequent dosing matters. And also with all my patients, I will ask some if they’re needle phobic, because I’m going to pick drugs that are injected less. And the IL-23 blockers have that advantage.

Mark G. Lebwohl, MD: Yes. I will say I agree with absolutely everything you said. What you haven’t mentioned, and I know you take into account, is the TNF blockers are great for psoriatic arthritis; OK, for psoriasis, but they have boxed warnings, which the IL-17 and IL-23 blockers don’t have.

Transcript edited for clarity

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