Plaque Psoriasis Treatment Goals


Jerry Bagel, MD, MS, discuss new targets, treatment goals, and utilizing shared decision making when treating patients with plaque psoriasis.

Jerry Bagel, MD, MS: The 3 most recent FDA-approved biologic agents for psoriasis are Skyrizi [risankizumab-rzaa], Tremfya [guselkumab], and Ilumya [tildrakizumab-asmn]. None of them have any blackbox warnings. None of them have box warnings. There’s no longer that fear people had when they watched between the end of ABC World News Tonight and Jeopardy! and there would be 3 commercials about psoriasis and they would say, “My psoriasis is affecting my life, I can’t live happily, I went on this new biologic agent and I feel great but I might die from tuberculosis or lymphoma.” You don’t see that anymore because these newer drugs don’t have lymphoma as a risk, they don’t have tuberculosis as a risk, they don’t have serious infections as a risk. And they work 90% of the time. What happens by getting into the IL-23 group you don’t have to worry about the inhibition of IL-12 that would increase infections. We got rid of that and we work with a much more selective group of molecules that can make psoriasis improve quicker, stay improved longer with a much better safety profile than before.

If you’re talking about psoriasis, the National Psoriasis Foundation’s medical advisory board, which I was part of, wrote up a treatise called “Treat to Target.” What “Treat to Target” really means is that we want everybody with 1% or less body surface area. My treat to target is 1% or less body surface area, so essentially clear or very close to clear. So that’s my target. Now, if the person has psoriasis arthritis though, we have to deal with the arthritic components as well, so we want to make sure that their arthritic components are significantly improved. Sometimes we have somebody on a drug where their arthritis gets better and their psoriasis doesn’t. Sometimes we have somebody where their psoriasis gets better and their arthritis doesn’t. We have to start to mix and figure out how we’re going to deal with that. But those are my goals; to clear.

It’s important to discuss the options but now that we have 12 FDA-approved drugs for psoriasis, it’s hard to discuss each option. For instance, the TNF [tumor necrosis factor] inhibitors we’re not using that much. The IL-17s we are using often. The IL-23 inhibitors we’re using very often. The IL-17s may work a little better for psoriatic arthritis, but they have the risk of inflammatory bowel disease, ie, ulcerative colitis and Crohns disease, so sometimes you want to shift away from them. On the other hand, any drug like Skyrizi [risankizumab-rzaa] or Stelara [ustekinumab], with 1 shot every 12 weeks, is really wonderful because that means if they clear, my patients don’t have to think about psoriasis for 361 days a year. I think the frequency of administration is also a big deal. When you talk about adherence as well, I think when I bring my patients in once every 12 weeks and they come, we know there will be better adherence than when you leave it to themselves.

Transcript edited for clarity.

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