James Song, MD, FAAD: Mark, you mentioned multiple sclerosis, your current typical inflammatory central nervous system disorder. Certainly, we have seen new cases as well as exacerbation of preexisting cases of multiple sclerosis—optic neuritis demyelinating disease, etc—with a TNF [tumor necrosis factor]–alpha inhibitor class. That would be 1 that I would certainly avoid. We actually have data that maybe the IL-17 inhibitors could potentially help multiple sclerosis. I think I’d lean more toward that. Ustekinumab was actually looked at in multiple sclerosis too. Maybe more of a neutral effect doesn’t hurt it but maybe doesn’t really benefit as much.
For anyone with a history of that, I probably would maybe favor an IL-17 or an IL-23 inhibitor, although we’d probably need more data on that class.
Mark Lebwohl, MD: Any other comorbidities?
Erin Boh, MD, PhD, FAAD: Obesity is 1 that that’s tough for many of us, especially for those patients who have some arthritis as well as obesity of metabolic syndrome. One of the things I like to go to when people have both is obviously something like infliximab, which not a lot of people use, and it’s got a lot of baggage. But it is useful sometimes for people who are very, very obese because it is weight based.
We have some other quasi-weight-based therapies, but I think infliximab is probably the best of them. Having said that, the newer drugs—the IL-23s—seem not to be as influenced by weight as the earlier drugs. I tend to now move a little more to the IL-23s because they do work well. It’s just that they’re, at least in my hands, not as effective for arthritis early on. If we stay the course and you get people on it for 4 or 5 months, then I see much more improvement with those, and they’re not as much in the weight-based category. But obesity is a tough one.
One thing I wanted to throw out and ask this group: The group I have most trouble with deciding—not deciding but getting a drug for, especially biologics—are our patients in the Medicare range. At least in our area, they are cutoff from everything except infliximab. It’s not that the insurances don’t approve them. Medicare approves them, but there is no way patients can pay for them. I would like to hear what you all do for patients who are in the Medicare range and their insurances don’t really pay for it. They approve it, and by approving it, the drug companies can’t give them drugs. In my area those are the patients I just scratch my head over, and I don’t know what to do with them if they can’t do infliximab.
Mark Lebwohl, MD: Put in perspective, the drug companies are not allowed to give coupons, discounts to the patients. The patients who have, for example, Medicare Part D, have a large doughnut hole, and then they’ve got to pay 5% of the cost of the drugs. If you have commercial insurance and you’re not a Medicare patient, that can be dealt with by the pharmaceutical company; they give you a discount. They can give you even a credit card that pays for that balance. But if you’re a Medicare patient, that’s against the law. I have my solutions. Leon, what would you do?
Leon Kircik, MD: A drug that has medical benefit rather than a pharmacy benefit—infliximab is 1 of them because of IV [intravenous] infusion, but the easiest 1 is still tildrakizumab. So tildrakizumab, because it’s given in the doctor’s office, is the only drug. Ustekinumab used to be like that but not anymore. With tildrakizumab you can get a medical benefit directly, but you have to buy and then charge Medicare directly. And you actually get about 4% or so revenue back, because you have the right to be able to charge 104% of AWP [average wholesale price]. It’s really a good deal for the patients, a good deal for us in all honesty.
Speaking of the metabolic syndrome, they have a recent poster. Mark, it was you or April Armstrong who was able to show that in the efficacy, there is no difference between patients with metabolic syndrome and no metabolic syndrome. That was a great eye-opener. It’s the first one I have seen in biologics; they did a really nice study. You can kill 2 birds with 1 stone because most of those Medicare patients are old, have high blood pressure, have diabetes, are obese, so it’s a great combination of getting 2 things together.
Transcript Edited for Clarity