Psoriatic Arthritis: Guidance for Switching Therapy

Lana Dykes: Under what circumstances would you switch therapies?

Christopher Parker, DO: A few. The first thing that comes to mind is I show up to the examination room and they’re already yelling loudly. Not yelling, but they’re complaining. If the patient’s unhappy with any particular medication because of adverse effects or inadequate efficacy, meaning how well it works—“Oh, it used to work and now it doesn’t,” Or, “It’s fading, it’s petering out,”—of course I’m going to switch therapy. “My insurance changed and now the cost is astronomical. I can’t do it even though it works great.” Again, that’s a really good reason to change.

Then I mentioned earlier there may be a situation for which a patient comes in and they’re happy, but I’m not. What do I mean? “Well, I checked your laboratory results, and they don’t look that good. I’m worried about your medicine.” Again, earlier you mentioned methotrexate. Say their liver function tests were getting funky or something like that, or as I mentioned earlier, we see destruction. If somebody is still having smoldering activity and getting damage by exam or by imaging, I’m looking to step up therapy even if they’re not. I’m thinking, “Hey, I want you to hang onto these joints for a long time and not have this.” So there are many reasons why I might change.

Lana Dykes: Do you ever switch between drugs of the same class or between different classes?

Christopher Parker, DO: Yes. I definitely do both of those things. Let’s say I’ve got 5 different tumor necrosis factor [TNF] inhibitors in my toolbox. Let’s say they’re on one. This happens with some regularity, where I’m treating psoriatic arthritis with a TNF inhibitor that’s by subcutaneous injection because they are easy and people have heard of them. They watch TV and commercials. It turns out they’re not having adequate control of their condition, either skin or joints or both, with that medicine. They’ve got some benefits, so they have a partial response. But, we see inadequate control. And so, maybe you think, “Well, maybe I should leave that class of medicines because they have inadequate control using a TNF inhibitor.” What I share in my clinic is, first, there’s no one-size-fits-all option. Second, note that these subcutaneous injections are one-size-fits-all medicine, so it’s a pen. Whatever size you are, the pen’s the same. And so, I share with them that if I gave a TNF inhibitor by IV [intravenous] infusion, now you have the opportunity to get a custom fit because they will literally check your weight every time you come in and give you the right dose based on weight. Many times, particularly in Texas, some of the patients are pretty big, you dose by weight and can get a dramatic improvement in efficacy, in that regard. I don’t let that benefit slip my mind. I also guarantee that they’ll get their labs done because they’re already hooked up. They make their visits because my nurse will keep calling until they schedule. It has those kinds of advantages, if they have those kinds of problems as well. That’s why I will frequently go with the same class.

However, to answer the other part of your question, why might I leave one class and go to another? Well, if I’ve tried one class and had very poor or no efficacy, I’m thinking this is not the solution for this person. Or, if I use a class of medicine, and I don’t know if it’s class-specific or not, but they had a very notable adverse effect or issue that came up that I thought might be related to that class of medicine, I want to leave that class. I’ll tell the patient, “This works nothing like the one that I just gave you, so I don’t want your mind thinking you’re headed for the exact same problem, if that’s what you have.“ Because in my clinic, I feel like the brain is super important. I spend the time in the clinic helping patients understand my thinking. If I do my job really well, when they walk out before they ever get the medicine they’ll say, “I feel better already.” Because that mind is already thinking this is going to work, and I want that benefit to happen. So I take advantage of that in the clinic.

Transcript edited for clarity.