Switching Therapies for Plaque Psoriasis


Advanced practice providers discuss scenarios in which they would consider switching between therapies when treating patients with plaque psoriasis.


Lakshi Aldredge, MSN, ANP-BC, DCNP: Let me ask you this. If a patient starts to lose efficacy in 1 class, do you try them on a different class altogether? Are you comfortable, or do you think there’s value in staying in class and trying a different agent within that class?

Matthew Brunner, MHS, PA-C, DFAAPA: The first part is what’s considered a treatment failure. If I’m seeing the patient back for 1 interval follow-up, and they’ve been doing well, where they recently started to worsen, I’ll have a discussion with him about giving it some time. We know there are triggers, as we mentioned earlier in our conversation. Patients may experience a loss of job, a physical illness, a hospitalization or surgery—some sort of a trigger for their condition. That’s true even in patients on systemic agents who are very strong and aggressive, like biologics. I like to see the patient back again after another 3 to 4 months and see how they’re doing. If the patient is continuing to show worsening of condition or lack of control, and I consider anyone who has more than 3% BSA [body surface area] to be losing efficacy on these systemic agents. If they’re losing efficacy, it’s time for us to move the therapy. If they’ve been a responder to a class, I have no trouble putting them on another agent in that same class because I know that mechanism of action has worked well for the patient in the past, and I assume that they’ve developed other antibodies or some other reason why that agent’s no longer working. I’ll move them to another agent, unless there’s some other presentation that leads us to consider moving to another class. How about you?

Lakshi Aldredge, MSN, ANP-BC, DCNP: You summed it up perfectly. There’s definite value if a patient has gotten really good results with 1, for example, TNF-α inhibitor [tumor necrosis factor-alpha]. Before completely jumping ship and going to a different class, I’d definitely try a second TNF-α inhibitor, especially if they have psoriatic arthritis or other comorbidities. If they’ve had a good response, I’m more apt to stay within class and try a second agent. If I start them in 1 class and they’ve gotten absolutely no response, then I might try going to a different class. Looking at their profile, understanding their comorbidities, if a patient doesn’t have joint disease or a lot of comorbidities, I might put them on an IL-23 first or even an IL-12/23 inhibitor. That’s a decision I would consider. It’s important to look at the whole picture. What has the patient tried before? How long did they use the medication? Did they get an initial good response? Did the response wane over time?

Another really important question is, were they using the medication properly? Were they consistent in taking the injections? Sometimes what happens with biologic therapy is they can be so effective that patients will think that they’re cured, or they’ll try to make their doses last longer and skip 1 here and there. That can also affect efficacy. It’s really important to have an honest conversation and make sure patients are using the treatments appropriately and also to see what’s going on in their life. If you have a patient who has been doing great on a medication and you see them back, and they’re just flaring horribly, before talking about it being a complete failure of the drug, ask them what’s going on in their life. Have they been more stressed? Have they had any other recent health issues? People can get the flu and see their psoriasis worsen. If they go in for surgery, the stress of that surgery might cause their psoriasis to worsen. They might go on vacation with their kids, and that can be stressful. It’s important to understand what’s going on in their life before you think about throwing an agent out as a treatment failure. You had mentioned that too.

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Transcript edited for clarity.

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