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Use of Systemic Treatment in Plaque Psoriasis

Opinion
Video

Dermatology experts discuss the use of systemic therapy in plaque psoriasis and determining patient response to treatment, also commenting on the use of PASI scoring in the clinical setting.

Alexa Hetzel, MS, PA-C: You guys are so brilliant, but due to her prior use of apremilast, the patient was placed on deucravacitinib, with a 75% improvement from baseline, which is incredible—15% all the way down to 3.5%. That’s significant. Lakshi, discuss your experience with the use of systemic treatments and how you determine response. What is response for you?

Lakshi Aldredge, MSN, ANP-BC: The National Psoriasis Foundation and the AAD [American Academy of Dermatology] came out with guidelines about what we should strive for, and you guys have mentioned it before. Ideally, we want all our patients to be 100% clear, but even less than 3%—ideally, less than 1% body surface area [BSA]—is really treatment success. The first end point the joint task force determined was that within 3 months of initiating treatment, they should have less than 3% body surface area involved. For me, it’s much more practical. Again, every patient presents differently. They may come in and have—much like this young woman—significant improvement but still have more than 3% body surface area. But they are thrilled, they are happy, and that is a huge success.

The other thing that’s really important to understand is that in the clinical trials, what we saw is even after the primary end point of, say, week 24 or even week 16, the efficacy continues to climb. So if you bring them back in, say, 3 months and they’re significantly better but still have some body surface involvement, you can [say], “If you’re happy with this [and] tolerating it, I would expect this is still going to get better in another 3 months.” But if they come back in 3 months and they [say], “I know I’m better, but I’m still really bothered by this and I don’t feel like it’s working as well as you described it to be,” then I’m going to be much more apt to transfer them or change them to something else.

The lovely data we saw with deucravacitinib [show] that they’re going to see continued improvement, so really it’s a matter of how well the patient feels like they’re doing on it. If I see significant improvement–they don’t have to be 100% clear—but if I see they’re moving in the right direction significantly within 3 months, I’m going to keep them on that regimen. If there’s not that movement—if they’re still having symptoms of itching, discomfort or pain, cracking, [and] if it’s involving the hands or the fingers—then I might be more apt to change treatments.

Alexa Hetzel, MS, PA-C: I think you nailed it. Just setting expectations and making sure they understand it’s not going to ever work like that, although we really want it to. Jennifer, you mentioned that you do clinical research in your office, [and] we do in our office as well. I don’t know [whether] anybody else does. [I use] BSA and [Physician Global Assessment] or [Investigator’s Global Assessment] in a practice office clinic visit. [However], when I’m evaluating patients in a clinical study, I’m using PASI [psoriasis area and severity index]. Do you ever use PASI in your office setting? I feel like it’s a lot.

Jennifer Conner, MPAS, PA-C: No, not an office setting. That’s strictly on the research side of the house. In the clinic, I’m using BSA and pretty much quality-of-life indicators. How happy is my patient? That’s how I’m judging how well the treatment is working.

Alexa Hetzel, MS, PA-C: It’s so funny because I feel like we talk about PASI a lot. That’s how it’s measured in studies and we put it in articles, [but] there are some people don’t know what PASI means. PASI 100 is not the highest or worst PASI you can have. The worst PASI you can have is PASI 72, which is so interesting [that’s] how the math works out and how it’s evaluated by each different area of the body. I think PASI is a great marker when you’re in research because you have the time to evaluate, but it’s impossible to then do all that math in the clinic setting and try to put that in your note. None of us have time for that.

Jennifer Conner, MPAS, PA-C: Absolutely not.

Transcript edited for clarity.

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