Treatment Selection for Plaque Psoriasis

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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