<p>While clinicians who treat plaque psoriasis are comfortable prescribing injectable biologic therapy, patients often prefer oral therapies. Our featured experts explore clinical and patient-specific considerations for treatment selection, sharing insights from their practices.</p>

The psychology around how patients make their choices between oral and biologic therapy for plaque psoriasis is fascinating. I think that all of us here would try to encourage our patients to use a biologic. They have high efficacy balanced with good safety. However, patients are often keen on using oral medications; many of my patients seem to be more comfortable with pills.

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I do think that there can be stigma associated with using an injection. In a patient’s mind, it may make the disease seem more serious. I recently saw a patient in the clinic who told me, “I saw my dad doing insulin injections when I was young, and I really do not want to go down that route.” This patient equates injections with more serious disease, so he chose to move forward with an oral agent.

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It will be helpful to see additional real-world data on some of the oral agents. Treatment adherence with oral therapies can be a concern. For example, patients may forget to take their pills, or they may stop treatment if they begin feeling better. Treatment adherence would likely be higher with a quarterly or annual injection. I will be interested to see that additional data down the line.

Every oral therapy is different, as is every biologic therapy. If I were to tell a patient that they only had to take an injection once a year—which might be available in the future—I think that they might opt for that over a daily pill, with everything else being equal. However, if I were to tell a patient that they needed to take an injection every month, they might view it differently. Or, if I were to frame the oral agent as being only half as effective as the biologic injectable, maybe the patient would rather have the more effective drug.

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Let us say that if blood tests were required during treatment with the oral option, this would steer a lot of people away from oral therapy if they did not have to do any blood tests while on the injectable, which is usually the case. So, every comparison between oral therapy and injection has to consider the features of the drugs that are being compared, as it is not clear which formulation is going to be the best for patients in every instance. I think that we will continue to have different patients using all these different routes of administration and formulations.

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In addition, I think that the choices for oral therapy are going to get better. There are a number of oral therapeutics in the pipeline, and, if US Food and Drug Administration (FDA) approved, they will likely raise the bar on how effective oral medications can be. The currently available oral medications for plaque psoriasis are not where they need to be from an efficacy standpoint, but that is likely to change, as we have not only an advanced, once-daily, oral IL-23R inhibitor but also several TYK2 inhibitors in development that may offer improved efficacy.

I agree that this answer is evolving. Those of us who have been in practice for some time are accustomed to working with the older oral immunotherapies, but newer clinicians are not exposed to them as much. There is a lot to know about these agents in terms of screening and monitoring requirements. However, I spend more time talking to my residents about oral small-molecule inhibitors and other newer oral options instead because I think that they will be using the older drugs less and less.

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Historically, we had often thought about oral therapies as step-through treatment for plaque psoriasis. As Dr Strober mentioned, they may not be as good as injectable biologic therapy, but they still work better than a topical therapy, and they provide a way for patients to try something systemic until they recognize that either the efficacy or the tolerability is not where it should be. Once they are comfortable with the idea of a systemic treatment, they can then go to the injectable.

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However, soon we will likely be in an era in which we might have oral therapies that are comparable to injectables in terms of safety and efficacy. That is going to then lead to very different discussions with patients, and it will be fun for us to rewrite our scripts for how we talk to patients about treatment. It will hopefully then be truly about patient preference, in terms of whether they want to take a pill once a day or, one day, have an injection once a year.

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I am curious to see whether patient preferences will change with the widespread use of GLP-1 receptor agonists. People are currently very willing to inject those agents. I think that patient preference and perception of injections may be very different a year from now.