Biologics Expand Treatment Options in Psoriatic Disease

Itching, burning, and stinging are hallmark symptoms of psoriasis, an immunemediated disease that causes red scaly patches on the skin. Raised and uncomfortable, these patches generally appear on the outside of the elbows, knees, or scalp but can cause more extensive dermal involvement. In about 30% of individuals who develop psoriasis, clinicians will diagnose psoriatic arthritis. Like psoriasis, psoriatic arthritis is chronic, but it inflames the joints and locations where tendons and ligaments connect to bone. It is associated with swelling, pain, fatigue, and joint stiffness, which interfere with activities of daily living.

At the recent National Association of Specialty Pharmacy Annual Meeting and Expo in Washington, DC, Jamie McConaha, PharmD, NCTTB, BCACP, CDE, associate professor of pharmacy practice at Duquesne University Mylan School of Pharmacy, and April Jones, PharmD, CSP, clinical specialty pharmacist at Vanderbilt University Medical Center, engaged specialty pharmacists in a concise but thorough presentation on these 2 diseases.

Dr McConaha noted that approximately 2% of Americans have psoriasis. It is bimodal in its onset, peaking at around 20 to 30 years of age, with the second onset peak after age 50 and before age 60 years. In the majority of patients, psoriasis precedes psoriatic arthritis, but other times both occur simultaneously or psoriatic arthritis precedes skin psoriasis. She emphasized that every time a patient who has psoriasis is seen by a health care provider, screening for psoriatic arthritis is essential.

In addition to covering the classification system used by most clinicians, she covered nail manifestations (pitting, distal onycholysis, and yellow-brown dyschromia) that are common, presenting in 50% of patients who have psoriasis and in more than 80% of patients who have psoriatic arthritis. Of great interest to the audience was her discussion of medical comorbidities. These patients are prone to develop metabolic syndrome, cardiovascular disease, and Crohn disease.

In discussing treatment options, Dr McConaha emphasized that ignoring the psychosocial aspects of psoriasis and psoriatic arthritis is akin to ignoring an elephant in the room. Health care providers need to assess patients for anxiety and depression precipitated by embarrassment and lack of self-esteem.

Treatment goals established for patients with psoriatic disease include reduction of pain, improvement of all signs and symptoms, optimization of functional capacity and quality of life, and inhibition of joint damage progression. Traditionally, a limited number of medications have been available, but recently, several biologics have been developed that inhibit interleukin (IL)-17 or IL-12/23. Among the former are secukinumab, ixekizumab, and brodalumab; in the latter group are ustekinumab, tildrakizumab, guselkumab, and risankizumab. After reviewing the data supporting efficacy, she noted that all interleukin blockers have some safety concerns, including risk of serious infection, reactivation of tuberculosis, exacerbation of inflammatory bowel disease, and hypersensitivity. She also warned against administering live vaccines to patients using these medications.

Finally, Dr McConaha reminded participants that it’s impossible to determine if the patient is responding to these biologics until they have been on treatment for at least 12 weeks. She also noted that patients considered obese or overweight may require higher doses. In addition, patients in whom one agent failed to produce a response may respond to another, and patient preference is an important consideration when selecting an agent.

Dr Jones then took the lectern to discuss the economics of psoriatic disease. As a lifelong, chronic condition, it can be costly. People who have psoriasis or psoriatic arthritis spend approximately $27,123 in annual medical costs compared with $5301 in people who do not have these diseases.

Early, accurate diagnosis following established guidelines can reduce the direct costs (emergency department visits or hospitalization, lab work and imaging, medication, and doctor visits) and indirect costs (absenteeism and presenteeism, poor quality of life). She compared costs associated with biologics with costs with conventional disease-modifying drugs, demonstrating that patients find biologics effective and are more likely to adhere to them, which may justify their cost.

Dr Jones summarized the specialty pharmacist’s role. In addition to drug procurement and Risk Evaluation and Mitigation Strategy (REMS) program management, initial counseling, and ongoing clinical monitoring, pharmacists need to be involved in vaccine management. Promotion of medication adherence is also a primary domain for specialty pharmacists. One of the biologics, brodalumab, currently includes a REMS program. It has a black box warning in its labeling because it has been associated with suicidal ideation and behavior.

Of particular interest was Dr Jones’s discussion of special circumstances. She reminded participants that patients who are experiencing bacterial, fungal, or viral illnesses should stop biologic therapy and resume it only when they have been feverfree, symptom-free, and treatment-free for at least 24 hours. These biologics also need to be halted 2 to 4 weeks before surgery if the patient is on an injectable and 1 to 2 days before if the patient is on oral medication. Therapy can resume based on surgical outcomes and after sufficient wound healing.

Overall, this session gave an in-depth review of the biologics now available for psoriasis and psoriatic arthritis. Both session speakers emphasized that these medications have the potential to help patients achieve clear or almost clear skin and prevent progression of psoriatic arthritis.