Clinical Practice Guidelines in Plaque Psoriasis

Melodie Young, MSN, RN, ANP-C: One other thing I wanted to mention. When you were talking about the guidelines, the drugs and science are advancing so quickly that guidelines—as many of us who contribute as authors know, it is a several-year process to get 1 developed and to get 1 published. No longer do you get it published and it’s time to redo it. It’s great to look at guidelines, and a lot of practices want to really follow them. But we have more problems with practices that are still coming up with their treatments from a decade or 2 or 3 ago.

If you want to be current and you think about what has come out in, say, the last 10 years—I want to use therapies that have come out within the last 10 years, and many of these have been out for a few years now—we have other resources for information that can speak to the safety. We have the Corrona data, the registries. We have the PSOLAR registry. Having 3 drugs within the IL-17 class and 3 drugs within the IL-23 class, those are the big decisions we now come down to. We’re going to use either the IL-23s or the IL-17s, unless, for some reason, there are other diseases for which we need a TNF [tumor necrosis factor]. Really, most clinicians now are going to use 1 or the other, and they still struggle with, which way do I go? Do I use an IL-17, or do I use an IL-23? It could be something as simple as the infrequency of dosing but also the safety.

One of the things you’re not supposed to do is look at the data. For example, you shouldn’t look at the data on risankizumab and say, “Well, here’s what we know about it, and it’s possible early data showing its use in psoriatic arthritis or its safety data.” And then we really shouldn’t say, “Well, we can assume that will be the same with guselkumab.” But it’s also comforting to know that when you don’t have black box warnings showing up in the IL-23 class and you can feel comfortable that something would have surely shown up with the amount of thousands and thousands of patients and patient years that have been looked at with the IL-23s, and even with the IL-12/23s, and the safety impact, and even with the IL-12/23 with ustekinumab. It has a pediatric indication. It has an indication for inflammatory bowel disease as well. So we do take comfort, and we do look at all these different classes of therapies and look at them in groupings.

When you mentioned the cancer part, if you watch to see, the FDA in the US is very, very rigorous. They have to have complete comfort with a drug before they’re going to let it be brought out into the public, and they want to make sure they have every detail noted. They want patients to be informed. We want our patients to be informed. We want to make sure they’re helping us make the decision. The last drug to even have warnings about cancer on the label was ustekinumab, and it was sort of an add-on based on prior information. It has been 10 years since we have had that. It’s not as common now that a patient comes in and says, “I don’t want to do a biologic. I’m afraid of a biologic.” That’s 1 of the things I’ll say. “Well, then, let’s use 1 that has come out in the last 10 years, because we haven’t had that label on there.”

Douglas DiRuggiero, PA-C: The importance of that meta-analysis is being able to say to patients, or say to each other, “The baseline risk for cancer is just because you have psoriasis.”

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: It’s the disease.

Douglas DiRuggiero, PA-C: The disease has an increased incidence in certain areas, as I talked about. So the question is, when you put them on IL-17s and IL-23s, compared with the general population, are we seeing a higher incidence of those patients who have psoriasis and are not on treatment, and those who don’t have psoriasis? And they really don’t. We’re not really seeing that cancer-risk increase, as you said, with the IL-17s or the IL-23s.

There are patients who are born completely deficient of IL-17. They don’t even make it. When they don’t have IL-17, they don’t really see any significant increase in cancer. What they see is erosive candidiasis in the throat, and that’s the biggest thing that they deal with. But they don’t really have patients for whom they think are completely deficient in IL-23. But that P450 site, people can be highly deficient in. Those folks develop infections, particularly salmonella and microbacterial infections. But again, I haven’t seen any data that said that those folks are developing cancers because they have a deficiency in those cytokines.

Again, it just leads you to that comfort level of saying, “Make choices in these 2 classes between what the patient needs are.” Does it have to be done in the office or out of the office? If they’re scared of shots and want to have less or more. If they have joints versus nonjoints. If they have inflammatory bowel disease and you want to avoid an IL-17 and do an IL-23. There are some nuances there, but it sure is nice to have 6 great options to choose from—3 on the IL-17 side and 3 on the IL-23 side.

Transcript edited for clarity.