What are the long-term risks of involuntary biologic switches for psoriasis care?
Brad Glick, DO, FAAD: Certainly if a patients doing well and we're pressed into switching to another agent because of a change of insurance, that's worrisome for me. I have a full-time biologic coordinator in my practice, and we strive very, very hard every day to make sure we're able to continue the patient on their current therapy. You know, if they have to switch, we've certainly tried to find a switch within that same umbrella. We now have 11 approved agents in the setting of biologic therapies for plaque psoriasis, which is, I think, our biggest reference point here, although we have an interleukin 4 and 13 blocker for atopic dermatitis, which we could also talk about. But categorically, we have 3 agents in the interleukin 17 umbrella, we have 3 agents in the interleukin 23 umbrella. And we have a whole host of agents that are tumor necrosis factor inhibitors for treating psoriasis.
So what I'm concerned about if someone is on, for instance, an interleukin 17 blocker, they're doing quite well, but I'm forced into perhaps a different therapy because of a change of insurance, I'm worried about first a lack of response. Some of the older agents have greater risks, at least from what we know in the literature. And in my experience into other infections. There are rates of background conditions, such as lymphoma, which probably are expected to some degree in individuals who have chronic inflammatory disorders like psoriasis, but they did occur in the clinical trials. And I have seen this happen in my 26 years of clinical practice. So in my opinion, I don't necessarily like going retro, if you will, to an older agent. But biologics are highly targeted and very successful therapies.
And so if I have to deviate to a different agent, we certainly discuss risk and benefit with the patient and their family. And we warn them about the different consequences of the different agents. You know, for instance, if someone was on an interleukin 23 blocker for their psoriasis, and let's assume they were doing fairly well, but they weren't completely clear, or they had mild disease. And we were looking to get them clear. And we decided to switch to a different class of agent. And one of the areas where we would switch to our agents we would switch to would be an interleukin 17 blocker, we'd have to check very carefully because some of the potential consequences of interleukin 17 blockers although uncommon, is inflammatory bowel disease. So if that patient has that comorbidity in the background, or there's a family history, one would have to consider a different therapy. So we look at patients so differently now in terms of sizing them up, and evaluating for the use of biologic therapies that many of these background comorbidities and prior uses of some of the older systemic therapies are pretty significant support for getting these agents approved, and we work hard to do so. So I think in answering the questions is a challenge.
But I think that we have to look at each individual patient, and there could be some potential consequences of switching. One of the other things before we move on is that you know, I worry about with certain agents like the TNF inhibitors, with neutralizing antibodies. Now that typically will happen over time with certain agents, let's say an infusible, agent like Remicade, but nevertheless, I think that the therapies that we have are so highly targeted right now, and many of the payers are starting to expand their treatment armamentarium, at least for us, our treatment armamentarium and our ability to use a lot of these agents and so hopefully, we don't have to switch so often. But when we do, we always have to explain the risk and benefit and what the particular nuances and consequences are of that particular biologic agent.