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 Let me ask you for last words of advice to our colleagues about how can dermatologists and rheumatologists facilitate a comprehensive approach for helping patients manage and treat the disease.

 I come back to the importance of evaluating each domain that the patient is presenting with, and not just focusing on the joints, in the case of the rheumatologist. In the case of the dermatologist, it is just on the skin. The disease is so much more than that, and it doesn’t take that much more time to quickly address the degree of enthesitis: Is there back pain? How is that doing? What’s the degree of nail disease? How severe is the psoriasis? Make sure no 1 of those domains is left behind when you’re approaching treatment. By addressing that each time, that teaches the patient to also be aware of the various domains, and they can comment to you when you’re on your virtual visits: “My back isn’t doing so well, although my joints are doing fine.” You can address each of those, and the patient is trusting that you are very comprehensive in your care. You are thinking about them, and to the extent that you can probe in a gentle manner about their emotional life, that goes a long way. It is just counseling people to be good doctors and take the time to do it. It’s extremely rewarding, especially these days when we have such a multitude of really effective medications that we can employ.

 I’ll throw in my 2 cents, which is that using a rheumatologist and a dermatologist together helps you get the right treatment for your patients in more ways than 1. When I went to medical school and I trained, I thought the best doctor was the guy who was not only dedicated to his patients, which most of us are, but who studied the most, learned the most, and knew the most.

That’s not true anymore. The best doctor is the guy who gets the best medicine and the right medicine for his patient. Sometimes, when you have a rheumatologist and dermatologist weighing in, as I alluded to earlier, you can get 2 drugs when you need them. If both of you have complained to the insurance company that they’re wrong—this is the right drug for the patient, not the 1 they’re telling me—and they hear it from 2 doctors, it helps the cause in getting the right treatment for your patient. I would use that as an advantage that many of us haven’t thought about but really is an advantage.

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Approaching Treatment for Patients With Psoriatic Arthritis

 Let me close with a couple of questions about a multidisciplinary approach by both rheumatologists and dermatologists. How can we help get that to optimized care? Do you do it at 1 visit? Do you do separate visits? How can gaps in care be addressed?

 My response on all this is education, education, education. There is so much lack of awareness beyond the medical dermatology and rheumatology communities about psoriasis and psoriatic arthritis and the optimum management of the conditions, as well as diagnosing the conditions. Psoriasis may be a little easier, but you could have comments about that to diagnose, because it’s there on the skin surface.

Psoriatic arthritis gets interpreted as osteoarthritis or fibromyalgia. In 1 study we did, the PREPARE study, it was found that nearly half the patients who were ultimately considered to have psoriatic arthritis were never aware that they had the disease. As new generations of medical practitioners come along, they have very little in their schooling. It’s so important to get education to nonrheumatologists and nondermatologists about identifying the diseases and triaging them to get to dermatology and rheumatology care. Once there, if you’re with practitioners who are not hesitant to pick up the phone, call your colleague down the hall or down the street to the other discipline—dermatology or rheumatology—and kibitz about optimal management. They are sharing, either by serial visits to their own offices or in with what is present in many academic centers and combined clinics, so both rheumatologists and dermatologists see the patient at the same time. The quality of care that’s coming out of this shared decision-making approach is really fantastic.

You raised a point about academic medical centers using a rheumatologist and a dermatologist together. We considered that, and in our polling patients we realized that there was going to be a problem in terms of a double bill—they were going to get billed by a rheumatologist and a dermatologist. Unfortunately, a lot of dermatologists don’t accept the Obamacare Affordable Care Act insurance plans that are out there. They have very high deductibles, they have significant co-pays, and their reimbursement rates are extremely low, so a lot of patients are paying out of pocket even if they think they have coverage. They come to an office and get to see a rheumatologist, and they get 1 bill that’s not well covered and then another bill that’s not well covered, and they object to having 2 bills. That’s why we did not do that at Mount Sinai.

We do have 2 people who are board certified in dermatology and rheumatology, but we opted not to have joint clinics in our clinic, which is largely a Medicaid population. We are actually working on having a board-certified rheumatologist and dermatologist as the person seeing them, but we’re doing it more for connective tissue diseases than we are for psoriasis. We’ll see how that evolves, and of course insurance will change if administrations change. If they stay the same, they may change insurance, and that may alter how reimbursements occur. Right now, it’s a drawback for us to have it together. As you know, there are organizations that encourage having dermatologists and rheumatologists work together. I can imagine it being a lot of fun; you learn from one another, you work together, and it is quite collegial. You’re together helping patients a lot, but the financial piece of it is problematic for us.

Optimizing Care With a Multidisciplinary Approach

 Let’s talk about the future. We already mentioned tofacitinib coming out for psoriasis. I believe it is being studied for psoriatic arthritis. Is that right?

 That’s right. In fact, I am presenting, at the American College of Radiology Annual Meeting, the psoriatic arthritis data from a phase 2 trial, which is very promising in all the ways that we’ve been discussing. It will move into a phase 3 program, and hopefully, at some point, we will see an improvement in psoriatic arthritis.

 I hope that will be the outcome. Tofacitinib, as you know, is approved for psoriatic arthritis. I will say, we have patients on occasion who do not do well with any of the biologics. When we switch them to tofacitinib—I’ll ask you a question about the use of tofacitinib with other drugs—their psoriasis and their psoriatic arthritis improved. It wasn’t approved for psoriasis because the FDA had concerns; it was an increase in cases of herpes zoster. They were worried it was too immunosuppressive, but in practice it’s proving to be fairly safe.

We do some blood monitoring, but unlike methotrexate, you don’t lose sleep over the blood monitoring you do for tofacitinib. Same with cyclosporine; you do lose sleep, so it is a pretty benign treatment that is quite effective. Tofacitinib, from what we’ve seen in the phase 2 trial, looks even safer, so I hope that will be useful in the future. I’ve always wondered, why does the package insert for tofacitinib allow its use with methotrexate but not with biologics, which we know are safer than methotrexate?

 Unlike the discussion we had earlier with apremilast, I would be a bit more cautious with a combination of JAK inhibitor and a biologic because they both have the capability of causing severe infections, so there could be some additive effect there. I’m generally more cautious about that particular combination recommendation until we see a formal trial that assesses safety with a combination between a JAK inhibitor and a biologic.

 My reaction to that is methotrexate is even more immunosuppressive, and we use that with biologics all the time. The answer is that it wasn’t studied, and it was studied with methotrexate, which unfortunately ended up with an increase in herpes zoster; biologics and tofacitinib were not studied together.

 I’m hoping that eventually we end up with the ability to prescribe these together. They will be safer than the combination with methotrexate, although that, of course, is very off-label.

 For us to break through our current situation, where we have patients failing treatments, we’re going to be pushed to do more experimentation with combinations.

 An exciting new development for both us of is bimekizumab, which has just great psoriasis skin scores and psoriasis joint scores. Would you agree?

 I believe that that 1 is probably due next summer, so hopefully we’ll be seeing that.

 It will be a little beyond that before it’s realized. We’re very excited about some of the data we’re seeing in phase 2 for psoriatic arthritis, and they’re in the midst of phase 3 trials now.

Looking Toward the Future in Plaque Psoriasis 

 Let’s talk next about the interleukin [IL] 17 blockers, which I think represented a breakthrough, both in psoriasis and in psoriatic arthritis. They are so effective for the skin and rapidly effective. We see in days an improvement in the skin lesions of psoriasis, and … in psoriatic arthritis, too. I’m just going to say they’re profoundly effective. We’re now no longer talking about Psoriasis Area and Severity Index [PASI] 75, we’re talking about PASI 90 or 90% improvement in psoriasis severity scores, so what’s their impact on psoriatic arthritis [PsA]?

: They do have very quick and profound effects on the skin. When they were introduced, there was sort of a bias that … maybe the tumor necrosis factor [TNF] inhibitors might work better in the musculoskeletal domains. But what we’ve seen is that these drugs work very well in all aspects of musculoskeletal disease: arthritis, enthesitis, spine disease, and now we have 2 recent head-to-head trials between the 2 approved IL-17 inhibitors and adalimumab, the SPIRIT head-to-head trial [NCT03151551] with the ixekizumab agent and the XC trial [NCT02721966] with secukinumab, and what has been shown is that both the speed of onset of action in the musculoskeletal elements as well as the magnitude of effect is just as good. They’re very similar and clearly, the IL-17s are superior in the skin and slightly better in terms of safety, and so I think that that has helped cement the place for ixekizumab and secukinumab. We anticipate additional IL-17s coming along to have a substantial place in the management of psoriatic arthritis, along with the TNF inhibitors.

: Now, along come the IL-23 blockers, and  now we’re not talking about PASI 75 at all anymore, it’s just PASI 90, and even PASI 100 for some of them. The other advantage of them is, they’re given infrequently, every 2 or 3 months, so certainly for the skin, they are profoundly effective and are so targeted, like the IL-17s, where they appear to be extremely safe.

The IL-17s have a small drawback in that they can cause Crohn disease, it appears. The IL-23s, probably, at the end of the day, will treat Crohn disease. It’s great for the skin and great for the gut. What’s the impact on the joints?

: From the data that we’ve seen, primarily from phase 2 trials with risankizumab and tocilizumab and phase 3 trials with guselkumab, we see that the musculoskeletal effects are comparable to what we’ve seen with the IL-17 inhibitors and the TNF inhibitors. There’s a question mark around their full benefit for the spine, but interestingly, 1 of the substudies in the guselkumab program was looking at patients with radiographically defined sacroiliitis in finding that their symptoms improved as well in the spine, so we’re hoping that this new drug class for us will have the same benefit across all musculoskeletal domains as the other biologics, and clearly  have very significant impact on the skin disease and are very safe.

: In terms of radiographic progression in joint disease, guselkumab has looked at that, and if you move the dosing to every 4 weeks, the American College of Rheumatology [ACR] scores aren’t that different than every 8 weeks, but in terms of the x-rays, it looks like every 4 weeks achieves the prevention of radiographic progression of joint disease. I will say also, these are not head-to-head studies, but the difference between active and placebo in the IL-23 blockers appears to not be as great as in the TNF blockers or the IL-17 blockers. Am I putting too much weight on that?

: It’s a little early for us to tell, and we need a little bit more time. I must say that I’d like to see the phase 3 programs for risankizumab and togekizumab

 coming along, but I think that what we're going to find is that these have a good, strong place in the armament. Just to comment on that radiographic observation, the once-every-8-week dosing came close to being statistically significant, so I’m not overly worried about it. I do think that it has the capability of inhibiting radiographic progression even though it doesn’t have a formal indication for that.

: Let’s just talk a little bit about the future. We already mentioned tocravicitinib coming out for psoriasis. I believe it is being studied for psoriatic arthritis, is that right? 

: That’s right. In fact, next week, I will be presenting as a late breaker in the ACR meeting, the PsA data from a phase 2, which is very promising in all the ways that we’ve been discussing. It will clearly move into a phase 3 program, and hopefully, at some point, we will see an improvement in psoriatic arthritis.

: I would have hoped that that would be the outcome. Tofacitinib, as you know, is approved for psoriatic arthritis, and we have an occasional patient who is just not doing well with any of the biologics. We switch them to tofacitinib, and their psoriasis and their psoriatic arthritis improved. Now, you know it wasn’t approved for psoriasis, because the FDA had concerns. It was an increase in cases of herpes zoster. They were worried it was too immunosuppressive, but in fact, in practice it’s proving to be fairly safe.

We do some blood monitoring, but unlike methotrexate, you don’t lose sleep over the blood monitoring as you do for tofacitinib. Same with cyclosporine. You do lose sleep, so I think it is a pretty benign treatment that is quite effective. Of course, tocravicitinib, from what we've seen in phase 2, looks like it’s even safer, so I would hope that would be useful in the future. I always wondered, why does the package insert for tofacitinib allow its use with methotrexate but not with biologics, which we know are safer than methotrexate?

: Unlike the discussion we had earlier with apremilast, I would be a bit more cautious with a combination of Janus kinase [JAK] inhibitor with biologics only because they both have the capability of causing severe infections, and so there could be some additive effect there. I’m just generally more cautious about that particular combination recommendation, until we see a formal trial that assesses safety with a combination between a JAK inhibitor and a biologic.

: My reaction to that is methotrexate is even more immunosuppressive, and we use that with biologics all the time. I think the answer is that it just wasn’t studied, and it was studied with methotrexate, which unfortunately ended up in an increase in herpes zoster. Biologics and tofacitinib were not studied together.

: I’m hoping that eventually we end up with the ability to prescribe these together. I think they will be safer than the combination with methotrexate, and that is my gut feeling, although that, of course, is very off-label.

: For us to break through our current situation, where we do have patients failing treatments, we’re going to be pushed to doing more and more experimentation with combinations.

: Yeah, I would agree, and I think an exciting new development for both us is bimekizumab, which has just great psoriasis skin scores and psoriasis joint scores.I believe that 1 is probably due next summer, so hopefully, we’ll be seeing that eventually.

: It will be a little bit beyond that before it’s realized. We’re very excited about some of the data we’re seeing in phase 2 for psoriatic arthritis, and they’re in phase 3 trials now.

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