Multidisciplinary Perspectives on the Management of Plaque Psoriasis - Episode 11
Mark Lebwohl, MD: Let’s talk about the future. We already mentioned tofacitinib coming out for psoriasis. I believe it is being studied for psoriatic arthritis. Is that right?
Philip J. Mease, MD: That’s right. In fact, I am presenting, at the American College of Radiology Annual Meeting, the psoriatic arthritis data from a phase 2 trial, which is very promising in all the ways that we’ve been discussing. It will move into a phase 3 program, and hopefully, at some point, we will see an improvement in psoriatic arthritis.
Mark Lebwohl, MD: I hope that will be the outcome. Tofacitinib, as you know, is approved for psoriatic arthritis. I will say, we have patients on occasion who do not do well with any of the biologics. When we switch them to tofacitinib—I’ll ask you a question about the use of tofacitinib with other drugs—their psoriasis and their psoriatic arthritis improved. It wasn’t approved for psoriasis because the FDA had concerns; it was an increase in cases of herpes zoster. They were worried it was too immunosuppressive, but in practice it’s proving to be fairly safe.
We do some blood monitoring, but unlike methotrexate, you don’t lose sleep over the blood monitoring you do for tofacitinib. Same with cyclosporine; you do lose sleep, so it is a pretty benign treatment that is quite effective. Tofacitinib, from what we’ve seen in the phase 2 trial, looks even safer, so I hope that will be useful in the future. I’ve always wondered, why does the package insert for tofacitinib allow its use with methotrexate but not with biologics, which we know are safer than methotrexate?
Philip J. Mease, MD: Unlike the discussion we had earlier with apremilast, I would be a bit more cautious with a combination of JAK inhibitor and a biologic because they both have the capability of causing severe infections, so there could be some additive effect there. I’m generally more cautious about that particular combination recommendation until we see a formal trial that assesses safety with a combination between a JAK inhibitor and a biologic.
Mark Lebwohl, MD: My reaction to that is methotrexate is even more immunosuppressive, and we use that with biologics all the time. The answer is that it wasn’t studied, and it was studied with methotrexate, which unfortunately ended up with an increase in herpes zoster; biologics and tofacitinib were not studied together.
Philip J. Mease, MD: That’s right.
Mark Lebwohl, MD: I’m hoping that eventually we end up with the ability to prescribe these together. They will be safer than the combination with methotrexate, although that, of course, is very off-label.
Philip J. Mease, MD: For us to break through our current situation, where we have patients failing treatments, we’re going to be pushed to do more experimentation with combinations.
Mark Lebwohl, MD: An exciting new development for both us of is bimekizumab, which has just great psoriasis skin scores and psoriasis joint scores. Would you agree?
Philip J. Mease, MD: Yes.
Mark Lebwohl, MD: I believe that that 1 is probably due next summer, so hopefully we’ll be seeing that.
Philip J. Mease, MD: It will be a little beyond that before it’s realized. We’re very excited about some of the data we’re seeing in phase 2 for psoriatic arthritis, and they’re in the midst of phase 3 trials now.
Transcript Edited for Clarity