Plaque Psoriasis: Individualizing Care for Patients With Moderate to Severe Disease
Individualized psoriasis care involves the consideration of disease severity and patient-level factors such as comorbidities, family history, and previous treatments. Additionally, patient preferences may play a particularly important role, especially in the absence of comorbidities.
How do you individualize care, what factors are critical in this process, and how important are patient comorbidities?
Professor of Dermatology, Pathology, and Social Sciences & Health Policy
“Educating patients on the many different available treatment options for psoriasis is a crucial first step in that it allows them to make informed individualized decisions.”
Educating patients on the many different available treatment options for psoriasis is a crucial first step in that it allows them to make informed individualized decisions. Sometimes, they choose something that I would not necessarily recommend purely from the viewpoint of the best disease control, and that is fine. For instance, some patients strongly prefer the oral route even though there are injectable options that are more effective. If the patient wants to avoid injections, that is completely acceptable to me.
Comorbidities are a part of the equation, but there is likely less of an emphasis on comorbidities in my practice as compared with that of my co-panelists. If a patient has psoriasis and inflammatory bowel disease (IBD), I would likely recommend avoiding the interleukin-17 (IL-17) inhibitors. However, I think that most biologics that achieve skin clearance are likely to have joint benefits as well. If a patient has some joint pain and psoriasis, I will treat the psoriasis and send them to a rheumatologist if they continue to have joint pain. So, in that sense, the presence of joint pain has little effect on my initial treatment recommendations. Further, I treat psoriasis because patients suffer from it, not because I worry that they may develop cardiovascular disease or some other comorbidity at some point in the future.
A patient’s response to previous therapies is another factor to consider. If an agent from one particular class worked well for a while and then stopped working, I would be inclined to recommend another agent from the same class. If a particular agent did not work well from the beginning, I would likely switch the patient to an agent from a different class.
Clinical Professor and Medical Director
“In patients with straightforward plaque psoriasis without comorbidities, individual patient preferences often play a significant role in treatment selection.”
It is important to consider comorbidities when selecting psoriasis treatments. For example, as Dr Feldman alluded to, for a patient with plaque psoriasis and/or psoriatic arthritis and IBD, I would avoid the IL-17 inhibitors and would likely start with a tumor necrosis factor inhibitor (TNFi). Alternatively, for a patient with psoriatic arthritis and no history of IBD, the IL-17A inhibitors or TNFi agents are efficacious and would be good choices. Direct IL-23 inhibition also improves outcomes in the skin and peripheral joints. Guselkumab has been shown to be efficacious (ie, US Food and Drug Administration approved) in improving arthritis symptoms and psoriasis, and tildrakizumab has been shown to be well tolerated and efficacious in improving arthritis and psoriasis through week 52. However, blocking the IL-12/23 pathway does not seem to be effective for the axial domain. Studies have reported that both ustekinumab and risankizumab failed to show clinical efficacies in ankylosing spondylitis.
Obesity is another comorbidity that can actually be relevant on several levels. Many patients with psoriasis already have a low self-image, so I will often defer a conversation about the importance of weight loss with a patient who is overweight until after we have treated their psoriasis and their skin has begun to clear, rather than discussing it during the initial visit. For a patient with psoriasis who is overweight and who may also have depression or appears despondent, the last thing you want to do during that first visit is to go into great detail about how important it is to lose weight. In terms of treatment choices, I am not generally influenced by the small amounts of weight loss (eg, with apremilast) or weight gain (eg, with TNFi agents) that have been reported in some studies. However, if I have a patient whose body mass index is quite high and they are not responding to fixed-dose therapies, I might seriously consider a treatment that offers weight-based dosing.
In patients with straightforward plaque psoriasis without comorbidities, individual patient preferences often play a significant role in treatment selection. I usually ask patients whether they prefer fewer injections or a faster response. If they want the skin clearance to occur as rapidly as possible, the IL-17 inhibitors are a good option. If they want fewer injections, the IL-23 inhibitors are a good choice, with some of them offering quarterly dosing, and they are highly effective.
Professor of Dermatology and Epidemiology
“One additional comorbidity to keep in mind is demyelinating disease. When there is a history or a strong family history of demyelinating disease, you want to avoid TNFi therapy.”
I generally agree with my colleagues and I will echo Dr Gottlieb’s point that it can be overwhelming for a patient to meet with us for the first time, especially since we have so many different treatment options to discuss. For patients with psoriatic arthritis, I would generally recommend a biologic therapy that is likely to benefit their skin and joints. If their joints do not improve, then they need to see a rheumatologist.
Regarding weight gain, there are some data suggesting that TNFi therapy can increase your weight slightly over time. However, I have not found that to be clinically important in my practice. In, fact, whenever I have asked my patients on TNFi therapy who appear to be gaining weight about this, in every instance, they have pointed to other factors as the sources of their weight gain (eg, they had stopped exercising or acknowledged that they had not been watching their diet).
One additional comorbidity to keep in mind is demyelinating disease, or a history of multiple sclerosis, optic neuritis, or Guillain-Barré syndrome. These conditions are uncommon, but you have to ask about them because many patients will not necessarily think to mention them, especially a single case of optic neuritis that may have occurred years ago. When there is a history or a strong family history of demyelinating disease, you want to avoid TNFi therapy in favor of IL-17 inhibitors or IL-23 inhibitors for patients with moderate to severe plaque psoriasis.
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