Bruce E. Strober MD, PhD, Professor of Dermatology and Director of Clinical Trials at the University of Connecticut Health Center in Farmington, CT, has dedicated most of his career to improving the quality of life for the millions of patients who live with psoriasis. And while we don’t have psoriasis cure yet, we are certainly getting closer. Dr. Strober talked to Practical Dermatology® magazine about what dermatologists can offer psoriasis patients today and where this field is headed.
What do the newly released joint American Academy of Dermatology and National Psoriasis Foundation guidelines for the treatment of psoriasis with biologics change?
Bruce E. Strober MD, PhD: The biologic guidelines intentionally are not prescriptive. Instead, they provide more of an open menu of how one can approach psoriasis. If patients need a systemic or biologic therapy for moderate to severe psoriasis, they should get it. This includes patients who don’t respond to topical therapy and those whose disease has a tremendous negative impact on their quality of life. In addition, patients who might have certain areas of the body involved that are refractory to treatment, such as the scalp, hands, and feet, may benefit from biologics even though the total body surface area (BSA) of disease is low. In these cases, BSA may not be more than five percent, but psoriasis has an immense effect on quality of life. The bottom line is that how the disease affects the patient is more important than absolute BSA.
Does cost affect access to care?
Dr. Strober: Yes, the modern drugs are expensive. However, there are a lot of routes that physicians can take to deliver these effective therapies to patients. It can be frustrating, because you can’t always use the medicine you most prefer as a first-line therapy. Some insurers stipulate that patients must try other modalities first. Fortunately, most of the manufacturers have programs for these drugs to be delivered either free of charge or at a low cost, but there are still steps that must be taken. It’s important to set up an infrastructure in the office to help patients gain access to medication directly from the manufacturer or through insurers. You need an educated person who works in the practice who is facile in the multiplicity of processes and is pretty well-versed about all the available medications.
What is going on with biosimilars in the US?
Dr. Strober: Biosimilars haven’t really infiltrated the US market because the primary branded (reference) drugs are still under patent protection and there are ongoing court battles seeking to retain this protection.
What psoriasis treatments are coming down the pike?
Dr. Strober: One drug was just approved by the FDA. AbbVie’s Skyrizi (risankizumab) is an IL-23 inhibitor that is given every 12 weeks as an injection, with the first two doses given four weeks apart. The efficacy data looks very good, and this will be an important addition to our treatment armamentarium. (For more on Skyrizi, see “Clinical Focus” on page 57.) In the next few years, we will probably see a small molecule, an oral novel tyrosine kinase 2 (TYK2) inhibitor from Bristol-Myers Squibb Company. It has just completed its Phase 2 studies now and it looks like the efficacy is quite similar to Humira (adalimumab, AbbVie) and Stelara (ustekinumab, Janssen), but we need to wait for Phase 3 results to verify this efficacy and better define its safety. We already have so many good choices. One of the major challenges is educating doctors on all of the available choices and what it entails to start patients on these drugs and monitor them appropriately.
Will we ever see personalized medicine in psoriasis care?
Dr. Strober: This is the Holy Grail and generates a lot of discussion at every meeting, but personalized medicine has not taken off in psoriasis to the level that it has in cancer therapeutics. We don’t draw blood and see this marker and say, “You should get this therapy.” The closest thing we do is look to see if a patient also has psoriatic arthritis and if they do, give them a therapy that is approved for and is known to be very efficacious for both psoriasis and psoriatic arthritis. n
See what Dr. Strober says about the influence of treatment on comorbidities online at PracticalDermatology.com.
Does blocking systemic inflammation lower risk for comorbidities?
Dr. Strober: We think that treating psoriasis may prevent the development of psoriatic arthritis. When it comes to reducing cardiovascular disease and mortality, some dermatologists believe that merely clearing the skin provides this benefit. However, it might be true that certain drugs are better than others at reducing the cardiovascular disease that is inherent to psoriasis. Many additional studies are required before we can speak confidently on the issue.