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AAD Preview: How to Choose a Biologic for Psoriasis Patients

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The upcoming AAD meeting is one that I am very much looking forward to. Not only is it a chance to visit with friends from around the country, it is also jam packed with must learn information. I’m going to be speaking on the impact of the patient’s history and comorbid diseases on biologic drug selection; I hope that everyone enjoys it.

Since the introduction of biologics, there have been various strategies for choosing the correct medication for the patient in front of you. In the past, we’ve recommended that efficacy drive the decision-making; this makes sense if the patient’s disease is very severe. In general, more powerful medications tend to work best at controlling the most severe disease burden. Another approach has been to use the time of onset to drive the decision about which biologic to choose. This too has merit, since we sometimes need a medication to work quickly, as in yesterday, and therefore understanding how quickly it will become efficacious is also a very important variable. And of course, insurance requirements have driven our decision about which medication to use, since often step therapy requires one medication to be used before another. Patient preference also matters; sometimes the timing of the administration of a given biologic can have a tremendous advantage for the patient. However, despite all these strategies, we still find that patients have tried and failed several biologics before they walk into our offices. So what happened? How can we get patients on the right medication first try?

In my talk, I outline the case for using the patient’s history as well as their disease comorbidity burden as another factor in the choice of a biologic. We’ve known for a while that obese patients do less well on biologics than their normal weight peers. We’ve also known that certain biologics may worsen other underlying inflammatory diseases — such as the IL17’s worsening inflammatory bowel disease or TNF’s worsening CHF. My group has recently demonstrated in a real-world study that the impact of obesity is greatest for the TNF’s and IL17’s, and less for the IL23’s. We’ve also shown that a history of diabetes similarly impacts outcomes. So not only is it important to screen for the metabolic syndrome and ensure that our psoriasis patients are seeing a PMD for their general health, but we now have come to understand that it has implications for the patient’s response to the biologics. Hopefully, this type of understanding will allow us to choose biologics agents with the best chance of success, thereby minimizing the biologic hopping that has become so common.

I would urge you to catch the rest of the session too. You’ll hear Dr. April Armstrong talk about the impact of psoriasis on our patient’s mental health, Dr. Bruce Strober talk about the challenging patient, Dr. Kristina Callis-Duffin talk on psoriatic arthritis, and Dr. Ken Gordon talk about putting it together for biologic selection. “So Many Biologics, So Little Time” should be a great listen for anyone who has psoriasis patients in their practice. Hope to see you there.

Dr. Van Voorhees reports research grant funding from Lilly and AbbVIe and consulting fees from UCB, BMS, Amgen, BI, and Novartis.

Image by Overearth / Shutterstock

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