How Do You Select Systemic Therapy for Your Psoriasis Patients?

In this exclusive MedPage Today video, Richard Warren, MBChB, PhD, professor of Dermatology at the University of Manchester in England, explains how he approaches selecting systemic therapy and what he considers to be the “mainstay of psoriasis management” right now.

Following is a transcript of his remarks:

Yeah, I think probably the key thing at the forefront of my mind is does the patient have psoriatic arthritis? Yes or no? And about one in five patients will suffer from arthritis, and that starts to direct — you need to be choosing a treatment that will cover the joints as well.

Of course, there’s other considerations. So some drugs are more robust in performing in people who are, for example, at a higher body weight. And you may also think about other comorbidities. So if there’s a presence of inflammatory bowel disease that would move you away from interleukin [IL]-17-blocking biologics and might push you towards more the anti-TNFs [tumor necrosis factor] or IL-23s. And then there’s lots and lots of other components. But I think the key one is really psoriatic arthritis. That’s one main discriminator that really sends me in one direction or another.

I think actually the IL-23 antagonists are, if you took health economics out of it — and it’s with someone just with pure plaque psoriasis, not psoriatic arthritis — they’re probably the go-to drug. The reason being they have a high level of efficacy, some 80% to 90% of people responding extremely well. But importantly, they have long-term efficacy as well. So patients, when they respond, they tend to carry on responding very well over many years.

They do work for psoriatic arthritis, and the data is not that they are on-label for psoriatic arthritis, but they don’t quite achieve the same level of ACR [American College of Rheumatology] response as the [IL-]17s and TNFs. But some would argue that they’re pretty good for some of the softer signs of psoriatic arthritis or enthesopathy or tendon insertion issues, et cetera.

So I think they are stalwart because they’re highly efficacious and highly persistent, and they’re also very safe. If we’ve been … as we’ve spoken about TNFs, and you shouldn’t use them in this scenario, and [IL-]17, shouldn’t use them in this scenario, it’s hard to think of a scenario where there’s a safety concern why you wouldn’t use a [IL-]23. Clearly all biologics carry a small infection risk, but otherwise — latent TB [tuberculosis], yeah, you’ve got to screen for it — but you could in theory, use a [IL-]23. Inflammatory bowel disease, it treats it. Psoriatic arthritis, it treats it. So, I think they really are a mainstay of psoriasis management at the moment.

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