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Utility of Spesolimab in the Management of GPP


Mark Lebwohl, MD, discusses the utility of spesolimab, the only FDA-approved treatment for the management of patients with from generalized pustular psoriasis (GPP), highlighting the rapid efficacy of this therapy.

Mark Lebwohl, MD: The presentation of this patient is almost what you would ask for because, before we had spesolimab and we would often use cyclosporine. The patient has renal disease, so if any insurance companies are telling you that cyclosporine has to fail the patient, that patient is out of luck. If they tell you the patient has to use methotrexate, she’s already got cirrhosis of the liver. So that’s a no-go. Now it turns out none of these drugs are approved for pustular psoriasis. In fact, the only drug approved in the United States for pustular psoriasis is spesolimab.

But had I been in your shoes, I would’ve talked about all the drugs you mentioned, including the TNF [tumor necrosis factor] blockers. Well, she gets a demyelinating disease, so they’re contraindicated. Ustekinumab is a little slow for a patient who’s acutely ill with pustular psoriasis. And the patient had been on ustekinumab before. But we would’ve done before spesolimab, exactly what you did. We would’ve started the patient on an IL-17 [interleukin-17] blocker. Why an IL-17 and not an IL-23? They’re just faster. They work pretty quickly, and the patient is really seriously ill.

But fortunately, we do have a new treatment, which is spesolimab. And I had the benefit of a late-night phone call from you, Erin asking, “What should I do?” And of course, the obvious answer is spesolimab, but the question is, “How do you get it?” So, I will say I never mind getting those phone calls. Because every time I prescribe this drug, I feel like I’ve saved someone’s life.

Erin Boh, MD: And it brings up a good point because when we requested the drug, it was approved, but it was set up in this funny umbrella way where you get it through your Medicare Part D or your prescription benefit service, which is an outpatient. And this is a medical emergency where I think many patients are having to be admitted for this acute generalized pustulosis, not the chronic flares.

So, the patient was admitted and the interesting part about this was that the insurance company approved it reluctantly; however, they have to go through a specialty pharmacy, which would not release the drug to a hospital unless it was part of the 340B Program, which we were not at the time. So, there were all these confounding layers. And so, Mark said exactly what you said, “Well, you tell them that if this patient dies, it’s on your back and it will not look good.” Well, the hospital CEO said, “Give it to her.” So, they bit the bullet and did the first one. But we did need a second treatment, and we can talk about that in a minute. The dosing regimen requires a second treatment about a week or so later. The insurance company worked out with the specialty pharmacy to have it sent, and then we were able to pick it up so that they wouldn’t deliver it to the pharmacy directly. And then we were able to administer the second dose. And so, it was very confounding.

But I think 2 points are very important. This drug works very fast, it’s very effective, but you have to get it to the patient. So, you really sometimes need to stick with it and be a little bit of a bulldog to get it if you don’t have the luxury of time. And so, I think that’s where you are prodding me to do that. As soon as you said that, I said, “Oh, great idea.” And so, then it moved it forward a bit. But I think if there’s a way that you can set this up in advance, meaning know your contact people before you get to the situation where you need them emergently is always helpful.

Transcript Edited for Clarity

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