Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 10

IL-23 Inhibitors in Plaque Psoriasis

Melodie Young, MSN, RN, ANP-C: Let’s talk about the things that I’m going to consider to be the more modern or the more progressive therapies. We’re going to focus on the IL-23s. We’ve mentioned the IL-17s just a little as being things we’ve talked about. So newer biologic options, particularly IL-23: Let’s mention tildrakizumab. Is anyone using that besides me?

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: I have not used it.

Douglas DiRuggiero, PA-C: Yes.

Melodie Young, MSN, RN, ANP-C: Why do you pick that?

Douglas DiRuggiero, PA-C: Well, I pick it because I’ve picked all of them. To be quite honest with you, when you see a lot of patients and you get known as a person who is aggressive with psoriasis and has success with it and spends time with patients, more people come to you. So when new medicines come out, I’m going to give them a try, particularly if I look at the data and see that it’s got good safety.

The question is, we have now 3 IL-23s out. Tildrakizumab went into development ahead of the others, but it was slower to come out.

Melodie Young, MSN, RN, ANP-C: Slow launch.

Douglas DiRuggiero, PA-C: It was a pretty slow rollout for them. Tremfya, or guselkumab, was really the first to come out. It came out in 2017 and was approved for moderate to severe psoriasis. So that was the first 1 out. It was nice because it continued the dosing regimen of Stelara [ustekinumab], and it was focused on IL-23, but you had to give it at 0 weeks, 4 weeks, and then Q8 [every 8 weeks]. So it wasn’t quite as long, but it still wasn’t a bump for patients to have a big transition to it.

I’ve had pretty good success with tildrakizumab. I’ve had success with all these. When we compare all these products with placebo, they’re extraordinarily better than placebo. The problem with the tildrakizumab is that it’s just a little slower to get to where you want it to be. The way Merck [& Co] designed the trial when it owned the product was it put the primary end point at 12 weeks. Everyone else has put the primary end point at 16 weeks in this new class. They didn’t have very robust data at 12 weeks. When they look at the data at 12 weeks, it’s better. But really, when they look at their data at 28 weeks, that is when it really starts to show that, “Hey, this is a product that should be considered in patients because it’s got great durability, it’s got good safety on its side, and also, it tends to be a product, tildrakizumab, that doesn’t care about obesity.” In other words, it doesn’t matter how heavy patients were. They had the same response.

The last thing I would say about tildrakizumab—I don’t have as many patients on it as I do the others so I’m not trying to overly hype it up—is that in some post hoc analyses with that particular product, they saw a drop in systolic hypertension and systolic blood pressure. They saw a drop in fasting blood glucose, and they saw an overall improvement in metabolic syndrome in patients who were put on tildrakizumab. It’s Ilumya [tildrakizumab]. It’s dosed at 0 weeks, 4 weeks, and then Q12 [every 12 weeks] thereafter. Tremfya is 0, as I said, 4, and then Q8 [every 8 weeks]. Then risankizumab is dosed at 0, 4, and 12 [weeks] as well. You have to give 2 shots with the Skyrizi, the risankizumab, each time you dose it. This is not the case with the other 2. So there are some differentiators in that IL-23 class.

Melodie Young, MSN, RN, ANP-C: There are a lot of similarities among all the IL-23s, and some differences as well. With ustekinumab as the last therapy that we had that was weight based, which is also known as Stelara, the drugs that have come since that time—the other 3 IL-23s, the weight does not affect the dose. But the dosing schedule, as Douglas mentioned… They all start with a dose at 0, and then 4 weeks later, and then it’s a matter of, do you redose at every 8 or do you redose at every 12? Some of them can be administered at home, and tildrakizumab is 1 of the ones that still needs to be administered in the office.

Douglas DiRuggiero, PA-C: That’s a point I didn’t make. It’s got to be administered in the office.

Melodie Young, MSN, RN, ANP-C: That can be a pro, and sometimes it can be a con. It’s a pro for me, because we have data as well that show that regardless of what you’re dealing with, the more intervention by the healthcare team, the healthcare provider, the better the adherence. Thus, the better the outcome that you’re going to get from that therapy. I have purposely put people on tildrakizumab because I did not want them dosing at home for a lot of reasons. Sometimes it’s because people start to get clear, and then they start to push their treatments out and go, “Well, if I am only supposed to dose every 8 but I’m so clear, what happens if I skip a treatment or if I push it back?” Or they start sharing with their family, friends. So there are reasons that would be good.

With risankizumab, which has just come out, we also had the opportunity to dose in the office. You might dose them for a while until you get them clear and then let them go. Then, also with guselkumab, it’s the same. You might dose them in the office to begin with. My rule is once you’ve been clear for a year, once we’ve been on therapy for a year, if home dosing is an option it would be something I would consider.

Douglas DiRuggiero, PA-C: Yeah, I think that’s an important differentiator between these. Also, for the Medicare patients the doughnut hole is a big problem. You can sometimes buy and bill and administer the Ilumya [tildrakizumab] in the office or, in our area, the local hospital. The infusion center allows us to send patients there and then be injected, so it’s treated as a medical device. That’s a great advantage to that.

Transcript edited for clarity.