Administration and Dosing of IL-23 Inhibitors in Plaque Psoriasis

Jayme Heim, MSN, FNP-BC: Regarding tildrakizumab, guselkumab, and risankizumab, those are the 3 pure IL-23s [interleukin-23s] that we talked about. Risankizumab is an IL-12 and IL-23. For these 3 pure IL-23s, could you discuss the route of administration and the frequency?

Matthew T. Reynolds, PA-C: With risankizumab and tildrakizumab, these are given at baseline at 1 month in and then every 3 months long term. Guselkumab is a little different; it has the same initial starting dose but it is given every 8 weeks vs every 12 weeks long term. Now, these drugs are given subcutaneously, and interestingly, most patients are doing these injections at home; they’re designed to be done at home. There is 1 product, specifically tildrakizumab, that is designed to be administered by a health care provider. It’s listed on the package insert. That’s how the clinical trials were designed. But it’s given that way because that is the way the drug company decided to launch the drug. Subsequently, by making it a health care­–administered drug, it was afforded a J-code by the FDA. And so, when you have patients that are given drugs in the office, sometimes an associated J-code is billed with the drug to allow for additional reimbursement. One other class of drug such as certolizumab is also administered this way, often both in rheumatology practices as well as dermatology practices. But these drugs are given every 2 to 3 months, again, because of the pathway that’s involved, that they’re specifically blocking the IL-23 pathway. Now, if you’re looking at overall adherence, I think the hardest thing for me is I can never tell which patients are going to do better with more frequent dosing or more loose dosing. More loose dosing means every 2 to 3 months. I think some patients just need you to do a little hand-holding and they need you to bring them in every month to give them their injection. However, in my experience, the patients that are getting the shots every 2 to 3 months do quite well long term. The adherence rates are actually quite good—especially when they’re achieving PASI [Psoriasis Area and Severity Index] 90, response rates are higher. For those patients that are specifically getting tildrakizumab every 3 months, I like giving patients tildrakizumab in the office because I think that they have this guarantee that every 90 days they’re going to get their shot, they’re going to get it on time, and I’m going to give it to them. So, administration is near 100%. Drug delivery subcutaneously is near 100%. That patient has a dedicated appointment with me every 3 months, and we can make tweaks and adjustments fairly quickly because we’re seeing them fairly frequently. Most patients that do these injections, such as guselkumab and risankizumab, are on an every 3- or every 6-month follow-up, and they’re doing their injections at home. But that’s just a little different for tildrakizumab. I think every drug has its own little nuances, but the dosing and frequency for each drug in the IL-23 class is just a little bit different.

Jayme Heim, MSN, FNP-BC: Matt, correct me if I’m wrong, but guselkumab as well as risankizumab can also be done in office injection?

Matthew T. Reynolds, PA-C: Yes, they can. That’s a service that you can provide for your patients. I have a lot of patients that do that. They just like for us to give their injections, and that is certainly an option for those 2 drugs as well.

Transcript edited for clarity