Underuse of biologics distresses patients

Miami Beach, Fla. - The new biologics remain untapped by a majority of dermatologists, which may be much to the chagrin of dissatisfied psoriasis patients who feel they have not been treated aggressively enough.

"The first wave of dermatologists who use biologics has occurred, but there still is a majority of dermatologists who don't use these," Dr. Kirsner reports.

Filling a need "Biologics fill a need for alternative therapies, especially in the patients' eyes," he tells Dermatology Times. "Patients want these therapies because standard therapies, in a global sense, are not satisfying patients with psoriasis."

He suspects that dermatologists do not fully recognize patient frustration with current therapies. Human nature is to remember patient successes rather than failures, and dissatisfied patients can be lost if they do not return for follow-up visits.

"Dermatologists don't experience the frustrated patient, and this is contrary to data that indicate patients with psoriasis are often dissatisfied with their care," Dr. Kirsner says.

He recognizes that significant toxicities are associated with standard systemic psoriasis therapies and can understand why dermatologists proceed with caution. He suggests that biologics provide dermatologists with a good answer to the toxicity concern of systemic agents because biologics are, "more targeted therapies, generally require less laboratory monitoring and have a more favorable side effect profile. This allows dermatologists to prescribe systemic therapy more comfortably."

Good news That is good news for psoriasis patients as well as for patients suffering from other inflammatory conditions.

He says that as a clinician prescribes biologics more often and his or her comfort level with them improves, then off-label uses could be pursued. Dr. Kirsner reports that infliximab (Remicade, Centocor, Inc.) has been studied and found to show promise in the treatment of inflammatory dermatoses, including hidradenitis suppurativa and ulcerative pyoderma gangrenosum.

Dr. Kirsner also supposes that the method of delivery - injection - of biologics is perhaps another stumbling block to some dermatologists.

"Dermatologists have not had the opportunity to deal with a lot of injectables. It is a lot easier to say, 'Here's a cream. Use it. It works.'"

However, he points out that a sufficient amount of scientific information exists to support biologics and the injection delivery method.

"The science behind it is impressive, but sometimes people are overwhelmed by the scientific aspects of it," he comments. "Answers are available. For a lot of things we use in dermatology, there aren't any answers."

Four approaches To incorporate biologics, Dr. Kirsner outlines four progressive approaches for four different patient profiles: rotational, monotherapy, combination and off-label.

For the patient undergoing traditional therapy who is rotated from one systemic agent to another to avoid toxicities, he suggests rotating that patient to a biologic instead. These patients often have their psoriasis controlled and are rotating to avoid cumulative toxicity. For a patient with moderate to severe psoriasis who is seeking initial treatment, start that patient on a biologic drug from the beginning.