Practical Approaches to the Management of Plaque Psoriasis - Episode 9
Leon Kircik, MD: I have a question to the panel. What do you guys do with patients infected with HIV?
Erin Boh, MD, PhD, FAAD: I can tell you, most of them, I start with the anti-TNFs [tumor necrosis factor inhibitors], mainly because of the comfort level, it’s in the literature. There have been several peer-reviewed publications looking at not worsening of the disease. In rheumatic disease, the patients with HIV did quite well on the anti-TNFs. So, I do not use that as a contraindication, period. As long as they’re on appropriate heart therapy and they’re being followed, I use that. I also will go to the IL-12/23s [interleukin-12 and 23 inhibitors]. For me, HIV is not a game stopper for anything. I don’t say it’s not an infection, but it is not one that I put into the exclusion category for any of these drugs, truthfully. We just follow along with ID [an infectious disease specialist] and get counts.
There was a published paper a few years ago looking at all of the anti-TNFs. They saw that the viral loads really didn’t change that much, with the exception of infliximab, where it was a little bit higher, but it didn’t change the course. I usually will start with etanercept because of its short half-life; if they get in trouble, I can take them off. But I will quickly, if they don’t respond, go to adalimumab if they need to, or the IL-12/23s.
I haven’t treated but 1 patient with HIV with the IL-17s [interleukin-17 inhibitors], but it’s only because they’ve responded to the others. I don’t think it should be much of an issue as long as they’re appropriately treated. And again, all of these I do in conjunction with ID or with any other specialist.
Mark Lebwohl, MD: I think there’s a lot that is different from one state to another, because in the past, we were told in New York, you had to fail the TNF blockers. And I’m not sure if it’s because I just make so much noise, I challenge everyone when they don’t let me give the drug I want. But I am never asked any more to fail a TNF blocker. They allow me to go to the IL-17s and the IL-23s, which I do view as being less immunosuppressive, and they’re very targeted.
In my patients infected with HIV, I do use an IL-23 or an IL-17. The one caveat there is moniliasis is increased if your helper T cells are down. That was one of the early findings in fact in patients infected with HIV. And of course, IL-17 makes you a little more prone. But we have used IL-17 blockers with no trouble in patients who are HIV infected.
I’m curious, James, and then Leon, do they let you go to the other drugs, or do you have to fail TNF- alpha blockers first?
Leon Kircik, MD: You mean only in patients with HIV, or overall?
Mark Lebwohl, MD: Both.
Leon Kircik, MD: Well, overall usually it’s TNF-alpha inhibitors first. But it depends on the insurance. Sometimes it’s ustekinumab. They don’t have anything separate for patients with HIV, you just have to write a letter and explain the contraindication.
Mark Lebwohl, MD: Sure.
James Song, MD, FAAD: It’s exactly the same situation here in Washington state. It depends on the payer, but for the most part the TNF-alpha inhibitors or ustekinumab are the 2 they prefer.
Mark Lebwohl, MD: Yes. I don’t know if it’s just me, but if they don’t give me the drug I want, I challenge it all the time. We do have the 340B drug pricing program here, and I think the federal law that protects that…the insurance companies probably are nervous about challenging those prescriptions. I find that our failure rate, when the prescription comes from our practice, which is not a 340B facility, is about 50%. When it comes from that clinic in the 340B program, it’s less than 10%. They approve almost all of those prescriptions. We have found that very beneficial for us.
Transcript Edited for Clarity