The dermatology community has over the past several years gained important insights into the comorbidities that may exist alongside psoriasis. Dermatology clinicians who focus on issues like metabolic syndrome are, “realizing that a lot of times these patients are not seeing a primary care physician annually like they should be,” says Kara Gooding, MMS, PA-C, of the Center for Dermatology and Plastic Surgery in Scottsdale, AZ. As a result, those who treat psoriasis patients increasingly, “are just looking at patients’ overall health and making them aware that perhaps their glucose is elevated, or that they have elevated triglycerides, and that that they should be seeing a primary care doctor. But oftentimes that's really falling on our shoulders with these patients. These are not things that we have to do with biologic patients; really the only requirement is to do a TB test prior to initiation of a biologic.”
While most in the dermatology clinic will not directly manage systemic issues associated with psoriasis, they can counsel patients on healthy lifestyles and urge them to seek proper care from a general practitioner. Screenings at therapy initiation can help to identify underlying systemic concerns. According to Ms. Gooding, most patients are receptive to her assessing liver and kidney function, cholesterol levels, and other indicators, "not because we have to and not because the drug is going to have any impact on that. We’re just making sure that they’re overall healthy.” Patients generally appreciate the attention to their overall health, she notes.
A good sense of the patient’s overall health can guide treatment selection. Sometimes, “a tiny nuance in the patient’s history or presentation may lead the prescriber to select one particular agent over another,” Ms. Gooding says. An obvious example is when patients have evidence of psoriatic arthritis. As patients have grown increasingly more savvy, many come to the dermatology office with some knowledge of psoriatic joint disease. Still, she says, “You still are going to have those patients that ask, ‘What do you mean that the morning stiffness in my fingers might be psoriatic arthritis?’”
Use of biologic therapies continues to expand, and more patients than ever are receiving treatment, but some patients may still be undertreated. Ms. Gooding, who is on the faculty for the Biologic and Small Molecule Bootcamp directed by the Dermatology Education Foundation, believes it is important that both patients and prescribers are educated on treatment options.
“There's a lot of data out there to say that even moderate to severe psoriasis patients are still being under treated. A lot of these patients are still being treated with topical medications only,” she says. There are now 13 biologic agents on the US market, so the thought of getting familiar with all of them can be overwhelming. It’s acceptable to familiarize yourself with a single agent or class of agents, Ms. Gooding says. Then let your patient base guide therapeutic expansion.
“Say you have a patient that only has psoriasis, then maybe your best choice is to go to an IL-23,” Ms. Gooding suggests. “If they have comorbid psoriatic arthritis, then if you're comfortable, pick a TNF, or if you're comfortable with an IL-17; we have better joint data on those particular classes. Over time you'll determine there might be small nuances and maybe one is better than another in a certain patient population.”
Be prepared to counsel patients on the realities of adverse events and risks, Ms. Gooding notes. Commercials are required to state all risks of biologic agents, but patients require context and a review of their specific risk profile.
Prescribers who confront their apprehensions and get educated can help patients, Ms. Gooding says. “If you can pick a biologic to get started with, then certainly you're going to benefit a lot of your patients.”