Practical Approaches to the Management of Plaque Psoriasis - Episode 15
Mark Lebwohl, MD: What are some of the challenges? You mentioned the access in Louisiana, but let me have you take the lead, James. Is the cost a hurdle you have to get over, low rates of treatment adherence? Tell us about some of the challenges you face.
James Song, MD, FAAD: Access is top of my list, absolutely. It doesn’t matter how good the drug is, it could be a PASI [Psoriasis Area and Severity Index] score of 100 out of 100, if you can’t get it into the patient’s hand, it’s a useless drug, right? And there’s no question, these are very expensive drugs, and the amount of work that they put on your staff could be very onerous. In my area, I don’t know if this is the case for you guys, the smaller practices don’t prescribe biologics. They don’t have the staff to push those PAs [prior authorizations] and appeals through, so it’s really just the larger practices and the universities that are doing it. That’s a shame.
Until we can get pharmaceutical companies, regulators, and payers to get on the same page, I feel like this is going to continue to be a problem. I would say that’s number 1. Number 2 is the fear factor. I’ve found that getting some patients to understand they have a systemic disease that needs a systemic treatment can be very difficult. Then they have a neighbor who may have been on a biologic before, they had some type of adverse outcome, and it’s so hard to undo some of that misinformation. That’s a challenge because we have so many biologics that probably would work for this patient, but they don’t feel like they don’t need a biologic.
And then lastly, I would say treatment adherence. As wonderful as the biologics have been for us, if you look at long-term persistence, there was one study done several years ago that was saying about a quarter of patients are going to stop their biologic at the 1-year mark. That’s a lot compared to some of our other chronic conditions. And there are various reasons why that could be the case. Maybe the drug is no longer effective, maybe they’re having some safety or tolerability issues. Maybe they just don’t have insurance anymore. But I think that’s an area we need more research in, why do patients stop their biologic?
Leon Kircik, MD: Do you think they stopped the biologics because they got better? Or do you think they stop the biologic because it’s not working?
James Song, MD, FAAD: I think both. For my IL-23 [interleukin-23] inhibitors, that’s such an effective medication, I put them on it, they get 3 doses or something, and they’re completely clear. And I never see them back. I think they stop the treatments because they think they’re cured, no matter how many times you tell that they’re not. I think that is a problem with the IL-23 inhibitors. But some patients do lose their efficacy over time, as we talked about before.
Leon Kircik, MD: I think it’s difficult to fix something when they don’t see it. When the skin is clear, 90%of the people ask me, “Hey doctor, how long do I have to use this? When do I stop?” Or, “Why should I continue when my skin is almost 90% clear?” And it’s even almost difficult to convince the dermatologist, the treating doctor, to treat something that they don’t see. It’s hard. But I always tell them, “Look, it’s a chronic disease. It’s just like diabetes, you don’t stop your insulin, you don’t stop this.” But it’s difficult to convince the patient.
Erin Boh, MD, PhD, FAAD: Leon, I take pictures when they come in, when they’re at their worst. Then when they come in and they say to me, all the time, “Well, I look so good,” or, “I’m done, I’d like to see how I’ll do off of it.” You just pull out that picture, and I tell you, they say, “Give me the shot.” Because people do forget how bad they were as they get better. So we always show baseline pictures so that we can say, “No, remember, this was you,” and they go, “Oh.”
Mark Lebwohl, MD: And it can be you again if you stop taking the medication.
Erin Boh, MD, PhD, FAAD: Exactly.
Mark Lebwohl, MD: That’s a great trick.
Leon Kircik, MD: That’s a good one.
Mark Lebwohl, MD: COVID-19 [coronavirus disease 2019] has had an impact. A lot of patients were nervous, especially at first; we didn’t know, would they be more susceptible? Would they have worse outcomes? It looks like they’re not more susceptible and the outcomes might even be better for some of the drugs.
But a lot of patients were then self-administering the drugs at home. In fact, some of the IL-23 drugs that we give in the office, we would ship to the patient, show them how to give the drugs themselves because they didn’t want to come in. And we were inundated with patients with COVID-19 at Mount Sinai. But having said that, and we heard a little bit about this from Leon earlier about the difficulty with payments if you self-administer as opposed to give the medication in the office; do you recommend patients learn to self-administer biologics, Leon, especially because of the pandemic?
Leon Kircik, MD: Absolutely, especially elderly patients. Nobody wants to come to the office anymore, right? Nobody wants to sit in the waiting room, and I don’t blame them, I agree. So absolutely they can, and they should be able to administer the drug at home.
Mark Lebwohl, MD: But what is the financial impact of that on the patient?
Leon Kircik, MD: If we take the tildrakizumab out, the Medicare patients, they all can self-administer, there is no reason why they cannot. All the other biologics they can, the only problem is tildrakizumab, which we cannot. But that’s also every 3 months, so it’s OK if they come to the office every 3 months, it’s not a big deal. I think the benefit outweighs the problem, right?
Mark Lebwohl, MD: I think during the pandemic, at least initially, Medicare waived the requirement, and we were allowed to ship even tildrakizumab to patients’ homes. We actually supervised them by video on how to self-administer the medication. I could be wrong about this, but I believe it was billable as a medical benefit still.
Leon Kircik, MD: Yes, because during COVID-19 everything was off, even with clinical trials we sent people home with the medications. They administered it at home themselves, which is a no-no for the clinical trials. But we were able to do it, we were given the green light to do that.
Transcript Edited for Clarity