Considering Safety of IL-23 Inhibitors for Plaque Psoriasis With The Patient


Expert dermatologist comments on initiating conversations about the safety of IL-23 inhibitors with patients with plaque psoriasis, highlighting biologic-naive patients.

Bruce Strober, MD, PhD, FAAD: Jennifer, when you think about the safety of IL-23 inhibitors, what is your thought process first and foremost and what is your discussion with the patient who [has] never heard of an IL-23 inhibitor before they entered your clinic office?

Jennifer Soung, MD: [The] first thing I think about [is] safety. It’s so much easier now prescribing biologics, and when I have a bio[logic]-naive patient come to me [who is] nervous [or] hesitant about starting a systemic therapy, I go to my IL-23s because the infrequent dosing along with infrequent monitoring that we have to do go hand in hand together. When I think back to when we first started doing biologics 20 years ago, [we did] frequent monitoring of [laboratory results] every 3 months, [and] now I’m just monitoring after initial testing once a year as long as they have their primary care [physician]. [It] is so much [easier] taking care of patients [with] psoriasis now. It speaks to the robust safety data we have for the IL-23 class. The package insert is so easy to talk about with patients; we don’t have any boxed warnings, we don’t have to worry about opportunistic infections or malignancy, so for a bio[logic]-naive patient, it makes the conversation so much easier. The idea of Q12 dosing is so appealing.

Bruce Strober, MD, PhD, FAAD: When you start a patient on an IL-23 inhibitor, there’s very little you have to worry about from a comorbidity standpoint that the patient may bring in with them. In other words, if they had multiple sclerosis in their past or if they had cardiac disease or hepatic disease, I’m still comfortable using an IL-23 inhibitor [for] that patient because it’s somewhat of an inert mechanism of action [MOA] regarding other organs and tissues, and it focuses on the skin inflammation, the joints, and the ligaments because it has an effectiveness for psoriatic arthritis.

Benjamin Lockshin, MD, FAAD: Bruce, just to add to what you’re saying, when I think about articulating the safety to patients, I divide safety into 2 different groupings: the common and the rare and scary. And the nice thing is [in] the common, there’s very little to talk about. For the most part, when prescribing an IL-23 agent, I say, “All you’re going to feel is better. You’re not going to notice any day-to-day adverse effects attributed to the medication.” And switching gears in terms of the rare and scary, there are a lot of no’s: no signal for malignancy, no serious infection rates that we see higher than placebo, no candidiasis, no IBD [inflammatory bowel disease], no depression. All those things provide comfort to me and comfort to the patient. And [as] Jen said in terms of [laboratory results] monitoring, most of my monitoring is either for insurance or because of their underlying disease state rather than the medication they’re on.

Bruce Strober, MD, PhD, FAAD: [It] comes down to my old way of thinking about safety in drugs. Patients view drugs as their providers view the drug. If you feel a drug is overwhelmingly positive from a benefit-risk ratio, you’ll impart that sentiment to the patient. And the patient is much more willing to take the medication. IL-23 inhibitors are ideal because they don’t present to the provider a trepidation, a wariness, a fear that might be something we had with older drugs.

Jennifer Soung, MD: I’m curious. Are you [both] doing a TB [tuberculosis] screening after the initial TB test?

Benjamin Lockshin, MD, FAAD: I do it because I like the objectivity of it, and we have a higher rate of latent TB in my area where I practice because we have a lot of state department people and international travelers. But I like the recommendations from the American College of Rheumatology saying that after initial screening, if patients are [at] high risk, asking specific questions is enough. What are you [both] doing?

Bruce Strober, MD, PhD, FAAD: I’m of the belief that the data don’t support IL-23 inhibition or IL-17 inhibition as TB-reactivating mechanisms of action. I would say, and this is off label, that the need to do TB screening in a person about to [start] an IL-23 inhibitor is completely optional. And Ben, as you point out, [it] comes down to your geographic locale and your sense of risk in your population. But even then, it’s not like TNF [tumor necrosis factor] inhibition, which does present reactivation risk for latent TB. It’s not the same concept. We’re in an era now where the MOA we’re employing doesn’t reactivate TB. I’m a little lax about it, and therefore I don’t do yearly testing for people with TB for TB.

Benjamin Lockshin, MD, FAAD: I do it to eliminate any issues with prior authorizations and insurance.

Bruce Strober, MD, PhD, FAAD: That’s required, yes.

Jennifer Soung, MD: I’m similar, Bruce. I don’t do it proactively for that reason unless the patient has risk factors. And I find that I get a lot more false-positive [results], and then the patients are frustrated. So in my area, I think it’s patient dependent. I also see patients in an underserved area, so it’s [a] case-by-case situation.

Transcript is AI generated and edited for clarity and readability.

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