Plaque psoriasis is a chronic disease, and patients often need lifelong treatment. Understanding long-term treatment patterns using real-world data can provide insight into the therapeutic journeys that patients with plaque psoriasis are likely to undertake and the best treatment strategies for individual patients.

We are currently experiencing an epidemic of undertreatment of patients with plaque psoriasis. Many of our colleagues still do not use biologics or small-molecule inhibitors in their treatment of psoriasis, and, for those who do use biologic therapy, many only use older biologics vs newer, more targeted therapies that may be more appropriate for certain patients.

Because we are all creatures of habit, treatment paradigm shifts can be difficult to implement into routine practice when new therapeutic options become available. Evaluating the latest evidence, from both clinical studies and real-world data, can be helpful in reinforcing the value of changing our treatment patterns. We also see greater diversity and inclusivity with registry data drawing on a wide spectrum of demographics, which can give us a better sense of how a drug will behave in the general population.

Ideally, we choose the most effective treatments to help patients achieve the National Psoriasis Foundation goal of clearance, which is defined as less than 1% body surface area affected by psoriasis. How do we decide when and how to make a change in strategy to help patients reach this treatment goal? Real-world data can help provide evidence to support the use of different treatment strategies at different time frames. For example, if I prescribe an anti–IL-17 monoclonal antibody that is dosed monthly, but I feel that twice-monthly dosing would be more appropriate for a particular patient with obesity, there are real-world data to support that strategy. Insurance authorization can present challenges when making these types of treatment changes, and this is why real-world analyses—which can provide information beyond what phase 3 clinical studies can provide—are so important. I often submit real-world publications to insurance companies as part of an appeal, and I find that it can help with the approval process.

Medication dosing frequency is a key consideration when it comes to optimizing treatment adherence in patients with plaque psoriasis. For some patients, a longer dosing interval is preferred. Others might forget if the time between doses is too long, and they could miss their 8- or 12-week dose. Therapy interruption can become a concern because it could possibly lead to a lack of recapture when the patient does decide to restart therapy. Will the drug still work as well when they restart it? Should we switch them to a different drug or add on another drug? These are all important real-world considerations when treating plaque psoriasis.

There is no doubt that there are clinically relevant differences among the various drugs and classes regarding long-term retention of efficacy. We are learning this from emerging real-world epidemiologic studies of patients based on many sources from around the world that reinforce each study’s results.

Despite the efficacy of available treatment options, there is still a lot of attrition in real-world practice. Patients discontinue their prescribed therapy more frequently than I would expect. This can happen for a variety of reasons. Sometimes, patients may perceive that their medication has lost its benefit. Some patients do not take their medication at the prescribed frequency interval, or they may stop taking it altogether on their own accord because they have achieved some symptom improvement. And, as Dr Friedman mentioned, there can also be challenges with insurance authorization that impact patient adherence.

For all those reasons, when I start a patient on a biologic therapy, I can never be certain that they will still be on that agent 12 or 18 months later. Some of this is out of our control as physicians, but one thing that we can do is choose to start with the most efficacious drug for an individual patient. Using a drug therapy that has higher efficacy up front may lead to improved longer-term efficacy, better patient retention, and less need for switching to a different agent.

I believe in the need for continuous therapy for this chronic, incurable disease, but a lot of physicians may still advocate for intermittent therapy. This may be a disservice to patients. I understand fully that many of our patients are young, and they do not want to be on treatment forever. However, psoriasis is not a condition that is going to go away; therefore, it requires continuous, efficacious treatment delivered in a way that creates a successful environment for optimal patient adherence.

Dr Strober mentioned the need for consistent, continuous therapy, and I treat my patients the same way. The available studies reinforce this strategy, but I agree that our patients often still resist the idea of continuous therapy. They may take their medication intermittently without our knowledge, they might extend their dosing intervals further, or they might even stop treatment completely. Real-world data confirm that treatment adherence and persistence remain a major challenge in clinical practice, and they also give us other types of practical information that we would not learn from a clinical trial.

One area where real-world data have provided helpful information that can aid clinical practice is in the field of biosimilars. Real-world data collected on the comparability of biologic biosimilars with their innovator products across different diseases and patients confirm what we have learned from clinical trials. The efficacy of biosimilars has been demonstrated in multiple real-world studies conducted in multiple countries, with no increase in safety signals relative to their innovator products. Seeing these data replicated across multiple countries greatly informs our treatment choices.