Paradigm Shifts in the Management of Plaque Psoriasis: Advanced Practice Provider Perspectives - Episode 8
Matthew Brunner, MHS, PA-C, DFAAPA, and Lakshi Aldredge, MSN, ANP-BC, DCNP, share their experiences with tumor necrosis factor (TNF) inhibitors in treating plaque psoriasis.
Matthew Brunner, MHS, PA-C, DFAAPA: You and I have been practicing long enough to see these agents come into existence, so tell me a little bit about how TNF-α [tumor necrosis factor-α] inhibitors fit into your practice, how you've used them in the past, and how you're currently using them.
Lakshi Aldredge, MSN, ANP-BC, DCNP: Absolutely. TNF-α inhibitors were one of the very first biologic agents that became available about 25 years ago.How they transitioned the way that we treat our psoriasis patients is really remarkable. Research and development of TNF-α inhibitors and all of the currently available biologics have vastly increased our knowledge of psoriatic disease.
Fifty years ago, we believed that psoriasis was basically a skin condition. In the early 2000s, we realized that this was an immune-mediated disease. The TNF-α inhibitors target one of the primary cytokines in inflammatory disorders of the skin to stop or inhibit mechanisms that cause inflammation. In this case, inflammation causes the overproduction of skin cells.
TNF-α inhibitors have also been approved to treat a number of other autoimmune conditions, including rheumatoid arthritis, Crohn disease, spondylosis, spondylosing arthritis, and uveitis. They have helped transform the way that we treat inflammatory diseases.
We have 4 TNF-α inhibitors approved by the FDA to treat psoriasis and psoriatic arthritis—adalimumab, etanercept, infliximab, and certolizumab. All 4 of those agents specifically target the cytokine TNF-α, and all of them work well. Infliximab must be given as an infusion in an infusion center. We recommend use of certolizumab for moderate-to-severe disease during pregnancy, because it does not cross the placental border. If you have a patient who requires a biologic agent during pregnancy, certolizumab is a TNF-α inhibitor that has a safe profile.
TNF-α inhibitors, again, are one of the first biologics that we use. They have a really great safety profile. However, treatment with TNF-α inhibitors is associated with a risk of infection, new-onset and rising heart failure, onset of demyelinating conditions (eg, multiple sclerosis, optic neuritis, Guillain-Barré syndrome), and, potentially, cancers, although all of those risk factors are very rare.
When considering starting patients on TNF-α inhibitors, the most important question to ask first is whether there is any history of serious infections, specifically tuberculosis (TB) and hepatitis B or C infection. All patients should be screened for TB and hepatitis B and C infections before starting use of any biologic agents. You should also ask your patients about a history of cancer. Knowing that they have had a recent cancer (eg, breast cancer, prostate cancer, leukemias, lymphomas) and are 2 or 3 years out is important in helping you to decide whether therapy would be safe. That’s a discussion to have with patients and their oncologists. Finally, you want to understand their lifestyle. Most TNF-α inhibitors are given once weekly or every other week, so patients must be consistent and adherent with their drug regimen. They need to keep these medications refrigerated, so you want to ask about that. I have some patients who are homeless, and that's a challenge for them. Some medications can be given in the office, so that certainly is an option.
As you mentioned, Matt, some patients become nervous or frightened when you mention the concept of an injection, because they do not want to inject themselves. Some patients have a real, significant needle phobia. This may be a trigger for patients with a past history of drug abuse who may fear reigniting their risk of drug behavior. These are really honest conversations that you must have with patients. It’s important to talk about which treatment options are available, what they've done in the past, how it worked for them, what is reasonable, what their lifestyle entails, and, unfortunately, what their financial situation or insurance status is, because treatment with a lot of these biologics, including the TNF-α inhibitors, can be cost-prohibitive.
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Transcript edited for clarity.