Factors That Influence Choice of Drugs in Plaque Psoriasis

Mark Lebwohl, MD: If we had a blood test that tells us this patient’s going to get psoriatic arthritis, it would actually help a lot. It’s not always that easy to diagnose, and I will say, you all know that even our rheumatology colleagues are not that good at it. It really brings us to the question of which drug for which patient. One of the first things I look at when a patient walks in the door, are they obese? And if they’re obese, I’m not going to give them any of the weaker drugs. They’re definitely ending up on the more effective drugs: IL-23 [interleukin-23], IL-17s. Infliximab is given mg/kg. So if I used a lot of that, which I don’t, I would think about that.

If they have psoriatic arthritis, they’re probably going to get a TNF [tumor necrosis factor] blocker, which I used to use; now they’re probably going to get an IL-17 blocker. If they have inflammatory bowel disease, I can’t give them an IL-17 blocker. If they have cardiovascular risk factors, the data right now are fairly good for TNF blockers. It’s starting to come out for the newer drugs. And I think we will have it. Right now the data still are there for the TNF blockers. If somebody has hepatitis B, if they’re say HBsAg [hepatitis B surface antigen]-positive, that’s a whole new story, and I always will follow these patients in conjunction with a hepatologist, because you want to make sure that their viral titers don’t go up when you treat them. If somebody’s hepatitis C-positive, there’s a great study with Enbrel. But having said that, we have the new drugs that should be able to cure hepatitis C most of the time, or all the time almost.

So there are many factors that we consider, that we think about. And I’ll never forget, I was asked by the National Psoriasis Foundation to lecture over 100 patients who had psoriasis, and I gave this lecture called, “Which Drug for Which Patient?” And I had them all stand up. And then I said, “When I’m done reading the following list of comorbidities, anyone who doesn’t have 1 of those, stay standing. Everybody else sit down.” And I started with, “Are you overweight? Do you have hypertension, diabetes? Do you smoke cigarettes? Do you have joint pain? Do you have hepatitis B or C? Do you have lupus?” And I went through a long list of comorbidities, and then at the end I said, “OK, anyone who has any of those, sit down.” Out of 110 people, 1 was left standing.

I don’t like it when insurance companies tell me, “Oh no, you have to use this drug, even though you want to use that drug,” because they’re not thinking about the whole picture.

Brad Glick, DO, MPH: Sure.

Scott Gottlieb, MD: Mark, one thing that I wanted to also point out is, I tend to use drugs. You talk about how a patient walks into your office biologic-naïve. But bio-experience is something that we more commonly even come in contact with. And the IL-23s as a class, and 1 of the IL-17s, have very good data to suggest that using it in a bio-experienced patient is just as good as a bio-naïve patient.

Mark Lebwohl, MD: That is correct.

Scott Gottlieb, MD: And I definitely will write for those drugs, if not first-line, if I’m thinking about it and they’re already on a drug, I think about those drugs that are as good in bio-experienced as bio-naïve patients.

Mark Lebwohl, MD: Well, this has been extremely informative. Before we end this discussion, I’d like to get final thoughts from each of our panelists: Dr Han, Dr Glick, Dr Gottlieb.

George Han, MD, PhD: We’re very lucky to be in an era where we have all of these great options for our patients. And I think it’s important that we really push ourselves and push our patients to figure out what’s ideal and what’s a great outcome for them, because we have the capability to. And I think one popular word these days among the millennials is bespoke. And so I’m looking forward to a day and age where we can have a patient come in, we’ll ask them a set of questions, and we’ll find the right drug, which drug for which patient, right? That bespoke drug that’s ideal for them. And that’ll be great.

Scott Gottlieb, MD: Well, I think it’s amazing where we’ve come over the last 20 years, 30 years really. You think about bench to bedside research, and some basic scientists spends their whole life trying to get 1 piece of something, some breakthrough that might affect a patient, and here we’ve done all this stuff, from basic science to drug companies, manufacturers coming up with drugs, to people doing clinical trials. But really where we have to give the most credit is to our patients, who put the stuff in them that they had no idea what they were doing, and they really benefited so many people, and psoriasis treatment is different today because of them.

Brad Glick, DO, MPH: I couldn’t agree more. I think for me it’s really about the doctor-patient relationship, and really educating our patients about where we have come, and that there a lot of possibilities for them. I think it’s challenging for patients to want to make the move to coming see the physician, whether it’s their primary care physician or their dermatologist. Now when they come to us, we have a tremendous number of options for them. A full toolbox we can practice with targeted therapy and precisely, and really manage those comorbidities carefully without injuring our patients. That’s a really good time.

Mark Lebwohl, MD: I’m going to close with one of my favorite quotes from a close friend, Boni Elewski, MD, who said she can’t wait for the day to come when her residents ask her, “So what did psoriasis used to look like?” I want to thank you all for your contributions to this discussion, thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.

Transcript edited for clarity.