Stratification of patients for the treatment of plaque psoriasis based on comorbidities and prior biologic experience.
Lakshi Aldredge, MSN, ANP-BC, DCNP: One of the things I’m curious about is does it make a difference if a patient is biologic naïve and comes to you with moderate to severe psoriasis, vs a patient who has been on several biologic agents? Does that change how you approach which agent you’re going to put them on?
Matthew Brunner, MHS, PA-C, DFAAPA: It does, actually. For the patient’s biologic experience, I want to know what biologic they took and what their experience was. What adverse effects did that patient experience? Did they have a good experience? Did it work well for them? Was there some reason, such as loss of insurance, that they had to interrupt that? And if there wasn’t a reason not to restart that therapy. I will usually restart the patient on that therapy. If a patient had a loss of efficacy, they were unsatisfied, they had some adverse effect or lab abnormality, I will absolutely switch them to a different class. For the biologically naïve, approach them based on their comorbidities, their presentation, and what’s important to the patient. I approach them differently, but those are some of the nuances in terms of selecting an agent for them.
Lakshi Aldredge, MSN, ANP-BC, DCNP: One of the things about being a nurse practitioner [NP] and a physician assistant in dermatology is that we often manage the chronic diseases in dermatology, such as psoriasis and atopic dermatitis. Some of the roles that we play in the management of plaque psoriasis is that we can take the time to develop a relationship with these patients, spend some time educating them about their disease, reviewing all the treatment options that are available, and then really working with the patient to come up with a decision that’s going to be helpful for the patient and that the patient can live with and be successful with.
Nurse practitioners and PAs [physician assistants] can impact the quality of life of these patients with psoriasis and psoriatic arthritis. The most rewarding days I have are when I see those patients come in who were covered head to toe or who were just miserable in pain, who were socially isolating, but they happen to be on a good agent for their psoriasis and feel like they have a new lease on life. They’re engaging in their family activities. They’re holding down jobs and successful. They’re traveling and going on vacations. They’re going to the gym and working out, and subsequently, their diabetes is getting better under control. They’re losing weight. You can really see the transformation in these patients, and that’s something that’s really, as an NP, I really value. As a PA, Matt, you’ve seen these patients and transformed their lives, and it can be remarkable. When you counsel patients about psoriasis, what are some of the challenges you face in helping patients come to terms with their psoriasis and then helping them move past them and be successful in their treatments?
Matthew Brunner, MHS, PA-C, DFAAPA: The first challenge that I would like to pinpoint is helping patients accept the chronicity of their disease. Many patients come in with the expectation that there’s something we can give them, something we can do for them that’s going to make this problem go away. It’s important to have that discussion, as we’ve mentioned, over the chronicity of the disease. You pinpointed that those patients sometimes have trouble with compliance with their therapies.
Sometimes that’s because we’ve taught them that with topical therapies, they should use them intermittently. We have to make sure we educate our patients when we put them on a systemic agent, whether it’s an oral agent or an injectable agent, to understand that these are not intended to be intermittent therapies. These are therapies that patients are meant to initiate and stay on, unless there’s a reason the provider stops them from their therapy, or they’re having some health concern that they need to stop it. Because patients have become accustomed to using topical agents intermittently, they sometimes transfer that into systemic agents. We have to do a better job as practitioners of educating our patients on that.
The other part is helping patients know when it’s appropriate to hold their objections if they’re on a biologic agent to recognize those concerns, but it can be challenging sometimes to coordinate with the rheumatologist or their primary care provider. Being able to communicate effectively as a part of the care team, with the other individuals who are responsible for the patient, is another crucial part of the puzzle.For the biologic naïve, it’s ]approaching the patient understanding their comorbidities, understanding their concerns. Will they feel comfortable? Was the patient more comfortable with us giving the injection in clinic? Is this something that would not at all fit for their lifestyle? That’s the proper approach to helping the patient and having that discussion about the appropriate education for them.
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Transcript edited for clarity.