Shared Decision-Making in Optimal Care of Psoriasis and Digital Tools: Making It Work in Practice Thursday, February 14, 2019
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Joel M. Gelfand, MD, MSCE Professor of Dermatology Professor of Epidemiology Vice Chair of Clinical Research and Medical Director Dermatology Clinical Studies Unit Director, Psoriasis and Phototherapy Treatment Center University of Pennsylvania Perelman School of Medicine Philadelphia, PA
Joel M. Gelfand, MD, MSCE Disclosures ● Research Grants (to the Trustees of the University of Pennsylvania): AbbVie Inc.; Celgene Corporation; Janssen Biologics, Inc.; Novartis Corporation; Pfizer Inc.; Ortho Dermatologics; Sanofi ● Consultant: Bristol-Myers Squibb Company; Boehringer Ingelheim; Janssen Biologics, Inc.; Novartis Corporation; Pfizer Inc.; Sanofi; UCB Data and Safety Monitoring Board (DSMB)
B. Jang Mi Johnson, PA-C Diplomate, Society of Dermatology Physician Assistants Senior Delegate to the AAPA House of Delegates Past President, Illinois Society of Dermatology Physician Assistants Past Sergeant-at-Arms, American Academy of Physician Assistants Senior Physician Assistant-Certified, Illinois Dermatology Institute Chicago, IL
B. Jang Mi Johnson, PA-C Disclosures ● No relevant financial relationships to disclose
Junko Takeshita, MD, PhD, MSCE Assistant Professor of Dermatology Assistant Professor of Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia, PA
Junko Takeshita, MD, PhD, MSCE Disclosures ● Research Grant (to the Trustees of the University of Pennsylvania): Pfizer Inc.
Shared Decision-Making in Optimal Care of Psoriasis and Digital Tools: Making It Work in Practice Thursday, February 14, 2019
Joel M. Gelfand, MD, MSCE Professor of Dermatology Professor of Epidemiology Vice Chair of Clinical Research and Medical Director Dermatology Clinical Studies Unit Director, Psoriasis and Phototherapy Treatment Center University of Pennsylvania Perelman School of Medicine Philadelphia, PA
B. Jang Mi Johnson, PA-C Diplomate, Society of Dermatology Physician Assistants Senior Delegate to the AAPA House of Delegates Past President, Illinois Society of Dermatology Physician Assistants Past Sergeant-at-Arms, American Academy of Physician Assistants Senior Physician Assistant-Certified, Illinois Dermatology Institute Chicago, IL
Junko Takeshita, MD, PhD, MSCE Assistant Professor of Dermatology Assistant Professor of Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia, PA
Case Presentation: JB ● 30 y/o female presenting with plaque psoriasis: scalp, trunk, elbows, knees, genitals, fingernail pitting and onycholysis ● BSA: 12% ● PGA: 3 ● Has had symptoms for 5 years, has been self-medicating with OTC treatments ● Demanding job with long hours ● Pruritus resulting in sleep loss ● When asked about joint symptoms, she noted that her knees ache ● Obese
Audience Response How would you treat JB? A.Topical treatment B.Methotrexate C.Biologic D.PDE4 inhibitor E.Phototherapy F. Not sure
1 Learning Objective Employ a proactive approach to the management of patients with moderate-to-severe psoriasis not responding to current treatments
PsO and PsA Treatments PsO Treatments 1-4 PsA Treatments 3-6 Topical Agents Moisturizers, topical steroids, tar preparations, dithranol, vitamin D analogues, NSAIDs ± vitamin A analogues Intra-articular steroids Oral Oral Treatments Treatments Anti–TNF-α PDE4 inhibitor Anti–TNF-α PDE4 inhibitor Anti–IL-17 Anti–IL-17 JAK inhibitor Anti–IL-12/23 Anti–IL-12/23 CD80/86 inhibitor Anti–IL-23 PDE4 = phosphodiesterase 4; UVA/B = ultraviolet A/B. 1. Adapted from Augustin M, et al. J Eur Acad Dermatol Venereol. 2012;26(suppl 4):1-16. 2. American Academy of Dermatology Work Group. J Am Acad Dermatol. 2011;65:137-174. 3. [Package Inserts]. Drugs@FDA Website. 4. National Psoriasis Foundation. https://www.psoriasis.org/files/pdfs/Treatment-Comparison-Chart.pdf. 5. Gottlieb A, et al. J Am Acad Dermatol. 2008;58:851-864. 6. Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-1071.
Secukinumab (CLARITY Study) a,b PASI 90 PASI 100 100 50 45.3 Secukinumab 300 mg (n = 550) Secukinumab 300 mg (n = 550) 76.6 Ustekinumab 45/90 mg (n = 552) 80 % Responders % Responders Ustekinumab 45/90 mg (n = 552) 40 38.1 66.5 26.7 60 54.2 30 47.9 20.1 40 20 16.7 20 10 5.7 0 0 0 0 4.0 0.7 0 0 0 4 8 12 16 0 4 8 12 16 Week Week a Patients inadequately controlled by topical treatments, phototherapy, and/or previous systemic therapy. b p < .0001 for secukinumab vs. ustekinumab at all timepoints. Bagel J, et al. Dermatol Ther (Heidelb). 2018;8:571-579.
Ixekizumab (IXORA-S) a,b Ixekizumab (N = 136) Ustekinumab (N = 166) Ixekizumab (n = 136) Ustekinumab (n = 166) 100 90 83.1 80 72.8 % PASI 100 (NRI) % PASI 90 (NRI) 80 70 59.0 60 60 49.3 50 42.2 36.0 40 40 30 20 20 23.5 10 14.5 0 0 0 2 4 6 8 12 16 20 24 0 2 4 6 8 12 16 20 24 Week Week a Patients had previously failed or had a contraindication or intolerability to at least 1 systemic therapy (including cyclosporine, methotrexate, and phototherapy). b p < .001 for ixekizumab vs. ustekinumab at all timepoints. Reich K, et al. Br J Dermatol. 2017;177:1014-1023.
Tildrakizumab (reSURFACE 1) a Part 1 Part 2 2-grade reduction from baseline, % of “clear” or “minimal” with at least 80 Patients achieving PGA score 60 40 20 0 0 4 8 12 16 22 28 Tidrakizumab 100 mg (n = 294) Tildrakizumab 200 mg (n = 299) Placebo — tildrakizumab 100 mg (n = 69) Placebo — tildrakizumab 200 mg (n = 72) a Patients were candidates for phototherapy or systemic treatment. Reich K, et al. Lancet. 2017;390:276-288.
Guselkumab (NAVIGATE Trial) a PASI 90 Response PASI 100 Response 100 100 Patients achieving Patients achieving PASI 90 relative to PASI 100 relative to baseline (%) 80 80 baseline (%) 60 60 40 40 20 20 16 20 24 28 32 36 40 44 52 16 20 24 28 32 36 40 44 52 Week Week Guselkumab Randomized ustekinumab (n = 126) (n = 113) a Patients were candidates for phototherapy or systemic treatment. Langley RG, et al. Br J Dermatol . 2018;178:114-123.
Apremilast (ESTEEM 2) a Period A Period B sPGA 0 or 1 response (%) b 50 (All patients on apremilast 30 mg BID) Patients achieving 40 Placebo Placebo/Apremilast 30 Apremilast p < .001 20 p < .001 10 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 Study Week a Patients were candidates for phototherapy or systemic treatment. b sPGA 0 = clear, sPGA 1 = almost clear. Paul C, et al. Br J Dermatol. 2015;173:1355-1356.
Selected Pearls from Hot Off the Press AAD- NPF Guidelines Recommendation Strength of Recommendation Number Recommendation Etanercept is recommended as monotherapy option in adult 1.4 patients with moderate-to-severe plaque PsO affecting the A scalp and nails It is recommended that infliximab be administered at a shorter interval (more frequently than every 8 wk and as frequently as every 4 wk during the maintenance phase) and/or at a higher 2.3 B dose up to 10 mg/kg for better disease control in some adult patients. Maintenance dose of adalimumab 40 mg/wk is recommended for better disease control in some patients. Adalimumab is recommended as monotherapy for adult 3.3-3.5 A patients with moderate-to-severe plaque PsO affecting the palms, soles (palmoplantar PsO), and nails. Elmets CA, et al. J Am Acad Dermatol. 2019. Published online February 13, 2019. doi.org/10.1016/j.jaad.2018.11.058.
Selected Pearls from Hot Off the Press AAD- NPF Guidelines Recommendation Strength of Recommendation Number Recommendation Recommended alternate dosage for ustekinumab is administered at higher dose (90 mg instead of 45 mg in patients weighing ≥ 100 kg) or at a greater frequency of 4.3 A injection (eg, every 8 wk in maintenance phase) for those with an adequate response to standard dosing. Secukinumab is recommended as monotherapy in adult patients with moderate-to-severe plaque PsO affecting the 5.6 A nails and palmoplantar plaque PsO Guselkumab is recommended as a monotherapy treatment option in adult patients with scalp, nail, and plaque-type 8.3 A palmoplantar PsO Elmets CA, et al. J Am Acad Dermatol. 2019. Published online February 13, 2019. doi.org/10.1016/j.jaad.2018.11.058.
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