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Review of Current and Novel Treatment Pathways to Manage Plaque Psoriasis - Episode 6

Plaque Psoriasis: TNF-α and IL-12/23 Inhibitors

Mark Lebwohl, MD, and Jerry Bagel, MD, MS, review the currently available TNF-α and IL-12/23 inhibitors used to treat plaque psoriasis.

Linda F. Stein Gold, MD: I want to switch gears now and delve more into the individual biologic categories that we have. And Mark, I’ll start with you, if you can just talk to us about the TNF [tumor necrosis factor] inhibitors and where do you see their role, and is there anyone you’re not going to use it for?

Mark Lebwohl, MD: Yes. My use of TNF blockers has dropped dramatically because we have drugs that are clearly more effective, and they don’t have the box [black box] warnings. I occasionally will use TNF blockers, but not often. I use them much more for off-label conditions like granuloma annulare, pyoderma gangrenosum, and others. And much less often for psoriasis. Occasionally, we’ll have a patient with Crohn disease who has psoriatic arthritis. And I don’t want to use an IL-17 [interleukin-17] blocker because it potentially might exacerbate Crohn disease. You know that several of the TNF blockers are approved for Crohn disease. That would be a common scenario for me to use it, but again, less and less often, is that happening.

Linda F. Stein Gold, MD: OK. And are there a certain patient population where they’re a no-go? Do you ask about congestive heart failure and that?

Mark Lebwohl, MD: The data on congestive heart failure is actually not that controversial. If you look at the clinical trial data with adalimumab [Humira], for example, they had less congestive heart failure in the adalimumab group than in the placebo group. When I didn’t have the current drugs that we have, I would call the cardiologist. They always gave me permission to use it. But for example, in demyelinating disease, you can’t have the patient on a TNF blocker, even a patient with a lot of squamous cell carcinomas or skin cancers, I would say that’s a no-go. I would not put those patients on TNF blockers. [The] same with the melanoma that’s not clearly cured. I would worry about using a TNF blocker in those patients.

Linda F. Stein Gold, MD: Other cancers is it a no?

Mark Lebwohl, MD: Most of the cancers that clearly have been associated with TNF blockers have been lung cancer in smokers, squamous cell carcinoma of the skin, and malignant melanoma is not statistically significantly increased. But it’s increased in every registry by a lot. It’s just less common. Lymphomas would be a no-go, too. Its data is controversial, but I believe there is an increase in lymphomas.

Linda F. Stein Gold, MD: Great. OK. Jerry, why don’t you walk us through your use of IL [Interleukin]-12, [IL-]23? Does it still have a place, and when?

Jerry Bagel, MD, MS: Sure. Ustekinumab [Stelara] was clearly our drug of choice for many years here at Windsor Dermatology. It was the best drug at the time I felt, or close to the best drug at the time, for efficacy, had a nice safety profile. It was the first 1 that 4 shots a year was giving 45% of the people PASI 90 [90% reduction in the Psoriasis Area and Severity Index]. And what I realized were the 2 things patients wanted were to be clear and to do nothing about it and ustekinumab was the closest thing to that at the point in time. And we had a lot of people on it and now we don’t. Now we have people that are still on it because they’re doing well. The ones that there’s data, which has shown that you can go from ustekinumab and if they didn’t obtain a PASI 90, about 75% of them on ustekinumab will. It really has. The only people I’m writing it for at this point are between the ages of 12 and 18 because even though there’s other biologic agents in that group, this is less shots. Kids want less shots. It makes sense for them. It's a good drug, but it’s not as good as what we have now.

Linda F. Stein Gold, MD: Interesting. I’m just wondering about the others. Leon, do you still have patients on?

Leon H. Kircik, MD: On ustekinumab you mean?

Jerry Bagel, MD, MS: Yes.

Leon H. Kircik, MD: Not as many. Very few.

Linda F. Stein Gold, MD: Not as many. Mark, what about you?

Mark Lebwohl, MD: Patients who were doing very well. I saw a patient today who’s a 100% clear, PASI 100, on ustekinumab. There’s not a good reason for me to switch that patient. I would say I probably saw 2 patients today who I kept on ustekinumab, but if there’s any psoriasis that is bothering them at all, it’s an easy switch to a [IL-]23 blocker.

Linda F. Stein Gold, MD: Yes. I agree with you. Any patient who’s doing well usually we left them alone as long as they’re happy.

This transcript has been edited for clarity.