Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 13
Melodie Young, MSN, RN, ANP-C: A lot of times physicians’ oaths would be, “First, do no harm.” We as NPs [nurse practitioners] and PAs [physician assistants] feel the same way.
Douglas DiRuggiero, PA-C: Same oath.
Melodie Young, MSN, RN, ANP-C: You do not want to do anything that’s likely to hurt them, so you would want to avoid something where there is a warning of a particular disease. Sometimes you can treat multiple diseases with 1 drug. They can have MS [multiple sclerosis] and psoriasis, so there would be things that you would need. But with the IL-23s, there aren’t many things or reasons why you would have to avoid a particular patient population.
Melissa Davis, PA-C: Even patients who had latent tuberculosis after they initiated therapy, at least with risankizumab and I believe also with guselkumab, they were able to start therapy in the clinical trials. Patients who had over a 5-year history of malignancy were included in the trials, at least with risankizumab. I’m not as sure about the other 1. I think that’s really reassuring for patients. Also, for those patients who have a history of malignancy, now we have an option for them, which is really nice.
I had a patient with a history of a malignancy, inflammatory bowel disease, and some infections. An IL-23 was the drug of choice for her, right off the bat, because all those other comorbidities prevented us from choosing 1 of the other classes.
Douglas DiRuggiero, PA-C: I just wanted to follow up on that if you don’t mind me being a little more on the science side. I just wanted to follow up on the cancer, because I want to point our colleagues to a large meta-analysis that just came out in the fall of 2019. It came out of New Zealand and Australia, but I think it’s the best comprehensive meta-analysis looking at malignancy and psoriasis that we have ever had. They reviewed 2300 trials and picked out around 50 to 55 of those that met some certain information criteria. It’s really the first time that we have a meta-analysis looking at the risk of cancer with psoriasis. They tried to stratify it by the disease severity.
It really showed that if someone has severe psoriasis, they do have an uptick in 8 different types of cancers, which included nonmelanoma skin cancer and lymphoma, but it also involved the esophagus, the liver, and the bladder. Those are all increased. But when they looked at psoriasis at all disease severities—mild, moderate, and severe—there was a significant increased risk in the lymphomas, particularly B-cell and T-cell lymphoma. We now have data that are showing that is the case.
There was actually a slight increase in incidence in 12 different types of cancers, which included those solid organ cancers as well.
Melissa Davis, PA-C: And these were nonbiologic-exposed patients, or both?
Douglas DiRuggiero, PA-C: It was both. They used all cohort and case-controlled studies. Again, it’s a meta-analysis looking at trials. It’s hard to stratify out other risk factors, because our psoriasis patients come in already with cancer risk factors. They tend to be more obese. They tend to be smokers. They tend to have more alcohol intake, and all these things, and sun exposure. It’s hard to stratify out all those other contributing factors, but I think most people would say this is the first meta-analysis and the best job of stratifying it out using the data, so it’s a good trial to look at.
Melodie Young, MSN, RN, ANP-C: Yeah. If you have psoriasis, you are at increased risk. We talked about all the cardiovascular components, diabetes, hypertension, obesity, depression, fertility issues, economic impact, divorces, and then also cancers. That goes back to being what Jennifer Cather, an interventional dermatologist, would say. “I’m using medications that are going to help heal people and help keep them from having the progression of their life and the impact on their life of all these diseases,” because we do believe in the inflammatory burden and how it is 1 of the most impactful aspects on causing you to have some of these issues.
“The best thing you can do to reduce your cancer risk, as we all know, is don’t smoke.” I talk to them about that. And, “Keep your weight under control, and avoid some of the lifestyle issues and environmental issues. If I can keep you feeling better and looking better and having just overall wellness, and I’m only spending a half hour a year, or maybe an hour a year of your time to treat your disease, hopefully you’ll have more time to impact the things that you can.”
Transcript Edited for Clarity.