Plaque Psoriasis: Dermatology vs Rheumatology

Mark Lebwohl, MD: Today, we can even do better. And the current crop of IL-23 [interleukin-23] blockers are so dramatically effective and the durations of remission are so good. And as we said, we’re not talking about PASI [Psoriasis Area and Severity Index] 75 anymore. We’re talking about PASI 90s for all of them.

Scott Gottlieb, MD: Which is I think another important point to make. We’re talking about PASI 90 and we’re saying X percentage of patients achieve PASI 90 and PASI 75. But if you’re PASI 89, you’re doing great, you’re so happy, and yet you’re a failure on this clinical trial. I think the mean PASI is a very good endpoint in terms of efficacy to look at these days because we all would agree that people who have very high levels of responses but don’t quite make the primary endpoint are still doing well. We’ve gotten so good that we’re a little warped in terms of who’s a failure and who’s not a failure.

Brad Glick, DO, MPH: That’s where patient-reported outcomes come in. I can tell you when the patient reports how they feel when they’re PASI 89, they’re quite happy.

Scott Gottlieb, MD: And how about when you walk into the room and you say, “Wow, you’re great,” and are so happy for them? That meets my endpoint.

Brad Glick, DO, MPH: And to your point, we really get to see it, we really do get to see it. It’s remarkable with these targeted therapies, no question.

George Han, MD, PhD: What’s interesting when comparing with other agents, while we’re on that topic, is looking at patients who come in on something like apremilast, because they were told by their previous dermatologist this is the safest medicine, it’s much safer. Honestly if you looked at the data, I don’t think they support that claim any more. Then we have a discussion about really balancing safety and looking at what the safety is with efficacy, which I think there is a clear benefit toward putting them on a biologic.

Brad Glick, DO, MPH: I think apremilast is pretty safe. But to your point, the bigger point is just looking at the combination of improvement with safety, and for me, I agree completely, it doesn’t measure out, with tons of patients on it. But for me, it’s really been more of add-on therapy, and certainly we have patients who are on monotherapy, but I don’t necessarily buy that from our colleague.

Mark Lebwohl, MD: And when we say it’s safe, there is diarrhea.

Brad Glick, DO, MPH: And living in Florida, I have a lot of patients with psoriasis over the age of 65. And the risks go up substantially for those patients over the age of 65 where apremilast is concerned. You don’t want them in the emergency department with full-blown diarrhea. So I agree.

Scott Gottlieb, MD: We’ve come such a far way in this disease state that I now tell patients who I’ve diagnosed with psoriasis, “You have psoriasis. It may be a chronic disease, you may need to be on medicine the rest of your life, but this will not affect the quality of your life.” I think that we’re that good these days we can say that.

Mark Lebwohl, MD: Yes.

Scott Gottlieb, MD: In thinking about where we need to go from here, I think psoriatic arthritis is still an area where we’re not seeing effectiveness of the drugs as much as we have with plaque psoriasis. I think trying to get more access to drugs with Medicare patients and things like that are going to be important things. And I think ultimately the story of psoriasis, the immunopathogenesis of psoriasis, we know so much about what’s going on, right? But we don’t know 2 things. We don’t know the beginning of the story, we don’t know the end of the story. We don’t know why it starts and we don’t know how it ends. I think that those are some of the things that I’m looking forward to coming down the road in terms of new areas of research and data.

Mark Lebwohl, MD: It would be very nice to have a drug that you can give as infrequently as every 3 months that also miraculously dealt with psoriatic arthritis as well as we are currently dealing with psoriasis. You earlier said, “We’re not doing so well.” We’re still stuck in ACR20s [American College of Rheumatology criteria] for psoriatic arthritis. There are some new IL-17A and F blockers coming that are very effective for psoriatic arthritis. And there are at least 2 that are reported for psoriasis, but their data on psoriatic arthritis are quite good as well. So we may be improving that, but they’re going to have to be injected more often than every 3 months.

Brad Glick, DO, MPH: SPIRIT-P1, P2, and also the head-to-head comparison with ixekizumab and adalimumab, I think that there’s a little bar raising there too, where there are ACR50s and 70s. I think that we’ve moved the bar so much in skin disease for psoriasis, but we haven’t yet in psoriatic arthritis. And I think our rheumatology partners, those doing clinical trials, and the company setting up the clinical trials know that, and I think that bar is being raised.

Mark Lebwohl, MD: And they are jealous of us, I would say.

Scott Gottlieb, MD: I think raising the bar with an oral agent would be another nice unmet need that we could look forward to, and I think that we are certainly working on that.

George Han, MD, PhD: But I think the first step really is the recognition, right? We all know to look for psoriatic arthritis, but it’s important that we all are asking questions. Axial disease is another aspect that people really underrecognize. It’s important we think about this, and at least ask our patients when they come in. As Dr Lebwohl mentioned, there are patients with maybe mild psoriasis but bad psoriatic arthritis. We might be that first point of contact for the patient coming into the health care system. Who knows? So I think the onus is on us to at least ask and try to figure out what’s happening.

Scott Gottlieb, MD: And make sure our patients are being well medically managed. I think that that’s also something that we often are remiss in doing in terms of the other comorbidities.

Brad Glick, DO, MPH: It seems that we’re still stymied with the number of dermatologists in the United States who are prescribing these remarkable therapies. Maybe the number is going up a little bit. Education has allowed for that. Are we doing better in working up our patients for psoriatic arthritis? I think this is a big issue. I think we are. I think the education for our dermatology colleagues, and really interacting with our rheumatology partners, has made us better dermata-rheumatologists, because I think that’s an important component of it. We need to be looking for it and making sure we’re getting it.

Transcript edited for clarity.