Melodie Young, MSN, RN, ANP-C: If you think about your own algorithm on what therapies you lean toward or lean away from—for example, if you have a patient with MS [multiple sclerosis]—are there any particular therapies you would try to avoid?
Melissa Davis, PA-C: Margaret and I were talking about this earlier, and I said I just feel like there’s not a cookie-cutter approach, or as you said, an algorithm, because every patient really has to be evaluated fully. What are their comorbidities? What is their family history? Like an MS patient, right? That patient cannot receive a TNF [tumor necrosis factor] inhibitor. So we need to know. Do they have a history of inflammatory bowel disease? An IL-17 is not the drug of choice for that patient.
Melodie Young, MSN, RN, ANP-C: Agreed.
Melissa Davis, PA-C: I wouldn’t say that when we evaluate our patient there’s not this algorithm that we have to step through necessarily, because we have to take each patient into consideration and then evaluate, as well as look at their insurance. If they are a Medicaid patient, even if there’s a newer therapy it may or may not be covered for that patient. So we have to evaluate all those things when choosing a therapy, I believe.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Of course, there are a lot of drugs that have absolute and relative contraindications. We know that as clinicians. We have to be very, very aware of that. That’s part of patient-shared decision making. We need to have those discussions. They’ve seen a commercial on television. They come in with this concept. “I want this pill.” It’s our responsibility to really do that good history to make sure. “Do you have a family history of MS?” There are things that we may have to push the limit with, but the key is that we need to be educated and understand that. We need to fully assess the patient, and then we need to talk to the patient so that they fully are informed about the contraindications and what Melodie said before. What’s probable? What’s possible? And talk about the adverse effects.
Then many patient preferences. Many patients come into my office and say, “I do not want a shot.” But they came through the door, and that’s how I see it. We have so many agents, and everything being equal, we have some amazing things. For patients who are so remote, they don’t want to have monitoring labs or don’t have the money to do it. Now we have these amazing new agents that have minimal baseline laboratory screening. That’s important. But assessing them, especially with malignancies, exposure; especially to things like tuberculosis and hepatitis; and their personal lifestyle, whether it’s alcohol or drugs, recreational drugs—those are part of the decisions that play into that.
Melissa Davis, PA-C: Or potential pregnancy.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Absolutely.
Melodie Young, MSN, RN, ANP-C: Yeah. This is a young person’s disease. Because most pregnancies are unplanned and are going to happen, and because you have to assume that females and males with this disease are in their 20s, 30s, and 40s, and sometimes even 50s, and there could be a pregnancy, and because there are some drugs that are absolutely contraindicated in pregnancy, the only ones for me that are an absolute no-no would be methotrexate, acitretin. Those are absolute no-nos if pregnancy is a possibility. I would prefer to know if it was in the future and in the plans, because we have 1 biologic agent that actually has done some small-study research looking at the impact of the drug on the fetus and on the baby through pregnancy and nursing. That is certolizumab, and I feel like it’s completely appropriate if somebody comes in and says, “Yes, I’m planning a pregnancy.” “OK, let’s start with that so I don’t have to make changes.”
I’ve also looked at certain therapies and realized that they’re about to turn age 65, and I have to think about what am I going to get covered for them because, all things being equal, of the 11 options, which therapy would be good for them? All 11 would probably help them tremendously, some better than others. But I’m thinking about which ones I am most likely to get covered later, so I don’t have to make a change and use something for a while. And then when they go into Medicare change, there are some that have better coverage than others.
Even with the people who say, “I don’t want to have an injection,” I’m just going to say that most of the time they don’t realize that, particularly if you look at IL-23s, you’re talking about 4 to 5 injections within a year. And some can be done in the clinic, and some can be done at home. So if they live far away...
Regarding the actual management of patients on these, you’re asked to do TB [tuberculosis] testing before a patient starts any of the biologic agents. But the ones that we’ve had in the last decade—the IL-23s and the IL-17s, particularly—don’t say anything about repeat TB testing. It depends on whether you feel it would be wise.
Regarding the lab management of a person before they start, a lot of times they don’t have primary care. And you know, the comorbidities. So you would love to know what their cholesterol is, and perhaps what their blood pressure and their weight is, because it can play a role with your dosing of particular drugs. But it also helps you see that overall picture.
Transcript edited for clarity.