Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 12
Melodie Young, MSN, RN, ANP-C: I feel like we should discuss, as clinicians who are going to be making decisions, which of these multiple choices of biologics do we want to pursue as being the best way to go for a particular patient. I wanted to hear from each of you what your thoughts are about IL-23s: the things that are similar and then any nuances. Are there things you think are different? Is there any patient type you would avoid, or patient type that you like to go toward? Margaret?
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: I love the IL-23s. I have limited access with tildrakizumab, and I love using it for patients who have moderate-to-severe plaque psoriasis and don’t want the dosing. They want the convenience. Both risankizumab and guselkumab are great. They just have to be prepared and be patient. I think that’s really, really good, and that’s the patient for whom maybe they don’t have the funding to do some of the serial laboratories that I do with other patients.
I will go to these, especially if I have a patient for whom I’m concerned of any comorbidity, like the inflammatory bowel disease, malignancies, or things like a family history of MS [multiple sclerosis]. There’s no reason to go there if I have this and know I feel confident in a really high clearance and pretty rapidly, just a little bit of a slow onset.
Where I see the difference is psoriatic arthritis or the potential for psoriatic arthritis. We don’t have the data published yet where I feel good about that. Whether the rheumatologist has talked to the patient and they’ve been diagnosed or I suspect it, I usually will go to an IL-17 as long as they don’t have that history of inflammatory bowel disease, understanding that I’m going to get a rapid clearance. They’re going to be happy with that quick clearance, and I feel good about being able to maintain it.
But I always let all my patients know that this is a chronic disease. You’re likely going to be on more than 1 biologic in your lifetime, and I like these because I’ve had patients who’ve been on acitretin, methotrexate, and TNFs [tumor necrosis factors], and these are hopes for patients who have had a lifetime of this and not been able to clear.
Douglas DiRuggiero, PA-C: I would echo the 1 phrase about psoriatic arthritis. Right now, out of all the IL-23s, while they’ve extended the dosing schedule, which is convenient for the patients and is very nice, and they have the nuances of in-office/out-of-office, as we’ve already mentioned, none of them has the FDA indication for the treatment of psoriatic arthritis. I’m not saying that’s not coming. In fact, there were some phase II data presented on 1 of the IL-23s last summer, in June, at the [Annual European Congress of Rheumatology], that showed very nice ACR [American College of Rheumatology] scores. So I think IL-23s are going to catch up and are going to do it. They’ve been out only since 2017, so we kind of have to do that.
If a patient comes in and psoriasis is a significant contributor or thought, I’m not going to put them on an IL-23 until the data are solidified. I am going to put them on an IL-17, even though the National Psoriasis Foundation is recommending that first-line treatment be TNFs. I have a lot of folks on TNFs who have psoriasis. I’m just seeing really good results, particularly with secukinumab, because now we’ve got several of IL-17s that have got data that show that it halts the progression of joint deterioration. I think that’s great. We’re even seeing our rheumatology colleagues saying that they’re using IL-17s in folks who have psoriatic arthritis.
We’ve got 2 good options if they’ve got a psoriatic component. We’ve got our TNFs, which are there, and we know work and help, and we’ve got IL-17s.
Again, if it’s irritable bowel problems, then an IL-17 is not the choice. They’re going to go on a TNF.
Melodie Young, MSN, RN, ANP-C: Because we have drugs that are already approved to do both. They will work on people with inflammatory bowel disease, and psoriatic arthritis, and psoriatic skin.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: We would pick a TNF then if you had that history.
Melissa Davis, PA-C: Or a family history.
Douglas DiRuggiero, PA-C: That’s right. And there’s even potentially going to be some data where the IL-23s are potentially going to be used for inflammatory bowel as well. We’ve just got to wait and see what’s going to happen with those. However, special patient populations are important because joints have to be considered, or risk of joint issues, and you have to look at these other comorbidities we’ve already mentioned—cardiovascular, metabolic syndrome, cancer risks. Because right now if there’s particularly a large risk of lymphoma or family history of it, you’re not going to put them on a TNF. That black box warning is there already. So you have to think about those things and ask those questions. We need to know a good family history and a good personal history, so we know which class to put them on.
Transcript edited for clarity.