Advances in the Management of Plaque Psoriasis - Episode 3
Mark Lebwohl, MD: I’m sure you’ve all discovered the patient where you say, “We could make you even better,” but they really insist they’re doing well, they like the treatment. What do you say to them?
Scott Gottlieb, MD: It’s tough. I infuse Remicade in my office, and I’ve been doing so for 15 years probably. And I have a group of patients for whom I say, “You could take this medicine, a medicine subcutaneously every 12 or every 8 weeks, whatever it is, and not spend Friday mornings in my office every 6 to 8 weeks, and they will not hear of it. It is very hard to make patients who feel that they’re doing well get convinced that they could have a drug that will either make them better or be more convenient for them. I’m going to ask the same question to you. How do you handle that?
Mark Lebwohl, MD: If patients are truly satisfied, I’m not going to twist their arm to take something that’s not broke and fix it. I have many patients who will have 1 patch or 2 patches left and they are so satisfied. And of course, I’ll offer them topical therapy. Sometimes they’ll turn me down with the topical therapy because once upon a time they were covered head to toe.
Scott Gottlieb, MD: Sure.
Mark Lebwohl, MD: But I will say I’m not going to force them to go on a therapy I think might be more effective. Now, I will say that that conversation changes when they’re on a treatment that I think may have more adverse effects. We’ll talk about adverse effects shortly, but the old TNF [tumor necrosis factor] blockers have warnings about infection and malignancy, black box warnings, and the new agents don’t. And even though those are uncommon, and the drugs are quite safe, they exist. There are people who get histoplasmosis, there are people who get coccidioidomycosis, there are people who get tuberculosis on TNF blockers who are at less risk if we put them on some of the newer drugs that we have. So if they have 1 or 2 patches, I say, well, not only is the newer drug more effective, it’s probably safer, and that often will get them to switch.
Brad Glick, DO, MPH: Particularly if they have very little left and they don’t want to initiate a topical therapy, you may be able to get them to another level of clearance even just with the systemic therapy alone.
George Han, MD, PhD: When you look at the evolution of biologics and our therapies in general, I think that in the early days you started seeing large effects and large improvements in the average PASI [Psoriasis Area and Severity Index] scores for our psoriasis patients such that with each successive generation and newer agent, you started seeing significant changes in the average improvement that patients could expect. Whereas nowadays, I think we’re to a point where with each newer agent, the average PASI improvements are really clustering very close to each other. So I find myself more optimizing, as you said, Dr Gottlieb, durability, safety, and issues other than just primary efficacy endpoints. Because I think in my mind, at least, that’s becoming a little less important of a distinguishing factor.
Brad Glick, DO, MPH: We can be thinking targeted—and targeted not specifically just short term but really in the long term—and make those decisions based on these responses, Dr Han, as you just mentioned, and also as it impacts, at least in the beginning, when we have these discussions about their associated comorbidities.
Transcript edited for clarity.