Jerry Bagel, MD, MS: With so many classes available, how do you go about finding the right fit and the right approach for each patient? Why would you select one class or mechanism over another?

Alexa Hetzel, MS, PA-C: When you think about patients who have psoriasis, about 30% of them are going to have psoriatic arthritis as well. That’s always a big factor. When I walk into a room and the patient has psoriasis, do they also have psoriatic arthritis? I ask them and look at their nails and scalp because we know that is a huge factor, and then ask them if they have swollen, tender digits, or swollen ankles or elbows. That’s going to help to determine where I go because biologic medications help differently with psoriatic arthritis than with just psoriasis. We’re both pretty aggressive in treating our patients, so it’s mostly going to be a biologic either way. I usually lean toward the IL-23s [interleukin-23 inhibitors] and the IL-17s because I don’t have to worry about my patients. That’s important, and also whether patients want to inject at home versus inject in the office. If I can get the medication, that’s important if patients don’t have insurance and they need samples. There are a lot of factors that go into it. Then, whether they are biologic-naive or experienced; if they are naïve, they’re a lot more hesitant and there is more hand-holding in the beginning to make sure they understand. Unfortunately, because patients have psoriasis for their whole life, sometimes they’re switching biologics because we haven’t found the right one that sticks with them. It’s a lot easier to say this isn’t really working for you, so let’s find the next option that’s going to work for you.

Jerry Bagel, MD, MS: A lot of it has to do with patients’ insurance, unfortunately. We’re in a good area in Central Jersey to get biologics approved, but even then if you can’t get it, or if people are over 65 and on Medicare, then you might want to get a biologic through a medical benefit because it’s more likely to be approved than if it was through a pharmaceutical benefit. If somebody has inflammatory bowel disease, I’ll definitely go with an IL-23 or Stelara because Stelara is FDA approved for Crohn disease and ulcerative colitis, and they’re developing the IL-23s in that category as well. Can you think of any other comorbidities?

Alexa Hetzel, MS, PA-C: I don’t think so, but GRAPPA [Group for Research and Assessment of Psoriasis and Psoriatic Arthritis] just updated their guidelines about including the IL-23s as good for psoriatic arthritis in first-line coverage so that we don’t have to choose the TNFs [tumor necrosis factor inhibitors]; sometimes we get denials for that. They have updated it.

Jerry Bagel, MD, MS: I think of one, depression, like suicidal ideation. For instance, Siliq [brodalumab] has a black box warning for suicidal ideation, so for anyone with severe depression, I would not put them on that. Even some of the IL-17s have sometimes been lumped into a group where there may be a problem with severe depression. It’s something to consider now that we have other options.

Alexa Hetzel, MS, PA-C: Do you think it’s patients with terrible psoriasis and that they were depressed because of it, or do you think that the medication really can cause depression?

Jerry Bagel, MD, MS: I actually think that. Brodalumab worked, when we did the clinical trials, faster than anything. I always felt that it worked so well for people with terrible psoriasis who weren’t going out of their house. They weren’t going out to do anything. They were like, “If only I can get my skin better, then my life’s going to be better.” They’d had this problem for 30 years, and they get Siliq, and they get clear and are clear 6 months later, but their life still is not doing well. They don’t have the coping skills to improve, they’ve never developed them. Then they’re really upset. I’m not going to promote that theory as a psychiatrist, but there could be some validity to that. Depression and certain drugs, even with Otezla, you must be concerned with as one of the comorbidities. But you hit it right with the psoriatic arthritis.

Transcript Edited for Clarity