Advances in Oral Therapies in Plaque Psoriasis

Lauren Miller, MPAS, PA-C: We have had some delay, especially in topical therapies, which we’ll get to, but a delay and sometimes a pretty wide gap between when we have therapies that are approved by the FDA for chronic diseases. But you’ll have people who will say, “Do we really need another biologic? Do we really need another systemic?” But [do you] agree with me that there’s still a need for therapies for plaque psoriasis?

Jayme Heim, MSN, FNP-BC: Yes, because not all therapies work for all people. So I look at it as more of their mechanism of action. I think that some people you talked about before, I mean, you had PASI (psoriasis area and severity index) 75 when you looked at it years ago, and yet there were still some of those patients who [had a] PASI 90 and probably 100, but they were very much the minority of patients, the very small percentage of them.

Lauren Miller, MPAS, PA-C: Yes, those are the ones we were doing case studies about.

Jayme Heim, MSN, FNP-BC: Yes, they were. Now we have patients who do respond better. But I think that a lot of times, even though we have also medications where even 7 out of 10 patients can get a PASI 90, or 6 out of 10 can get a PASI 100. They may not respond the way that we think they will. And that’s because those are free-range patients that we see in our offices. And if that’s not their pathway, that’s not their mechanism [or] that response to [it] for their psoriasis, they’re not going to respond to it. Sometimes they partially respond when you go through an induction phase and then when you go to a longer treatment phase, which is their maintenance phase, they don’t respond anymore. So, it’s good. It’s very good that we have all of these medications, and we do need to continue with the development of medications for patients with psoriasis.

Lauren Miller, MPAS, PA-C: So, speaking of PASI 75, PASI 90, PASI 100, those were typically things that we reserved for biologics when we thought of being able to get a patient to that level of clearance, we thought, “OK, that’s going to require a biologic.” We now have some oral therapies. Talk about oral therapies and the need for more oral and systemic options and maybe talk about your experience with the orals and what you’ve seen with those as they’ve come out. I think the last one was deucravacitinib, which was approved in 2022. And then before that there was a really big gap. I think it was 2014 that apremilast was approved. So there’s been this unmet need. When it comes to oral therapies, do you find that your patients are open to [them], and do you utilize those a good bit in your practice?

Jayme Heim, MSN, FNP-BC:I do. I absolutely do. And I think that, too, when you look at when apremilast was first FDA approved, I used a lot of apremilast, especially because there’s not that increased risk of infection with this medication. I had a couple of patients who were constantly having problems with infections. We had very little in regard to topicals, whether it be calcipotriene or topical steroid. You have to worry about the [adverse] effects of the calcipotriene when it’s a cream, it’s not very effective because…you really can’t get [the ointment] economically anymore. And then the steroids have a problem with atrophy after a while. But with the oral medications, there is another option for patients. Some patients tolerated apremilast better than other patients. It takes a longer time for that medication to reach efficacy, and the efficacy is not the same for a lot of patients that it was with biologic therapy. However, that being said…there are those patients who responded fabulously. No GI [gastrointestinal] [adverse] effects, and had a tremendous response, PASI 75 or more on apremilast. It was hard because of the [adverse] effects of medication. With the other medication, deucravacitinib, that medication has a higher response rate for patients. It’s also tolerated better [by] our patients. Overall, I think that generally patients still perceive that an oral medication is much safer than an injectable medication, [as] we saw when apremilast was first brought to market. Patients were coming into the office in droves because they had so much fear regarding injectable therapy, and here it was now an oral therapy. So, there, it was perceived as being more noninvasive.

Lauren Miller, MPAS, PA-C: Something about that needle really can scare patients away and often…patients, and just as…most of us take some type of supplement vitamin, over-the-counter product for headaches or joint pain…we’re used to oral therapy. We’re comfortable with that. It’s not as hard of a sell. Sometimes injectables, to a patient, can seem abrasive. And like you said, they take that as meaning, “There must be more risks with this because it’s an injection.” I find that my patients are very open when I talk to them about the options. It’s just we haven’t had very many. So I think about the fact that there was an 8-year gap between apremilast being approved and then deucravacitinib being approved. That’s 8 years that we went without having another oral option for patients who maybe were needlephobic or for whatever reason were not candidates for biologics. If they had tried apremilast and some of the standard options previously, methotrexate, cyclosporine, and they had run out of options, what were we doing [to treat] those [patients]? It’s really an unmet need that that was really an issue. So I’m very grateful to companies, as you said, that put their time and effort into research and development with that. How often would you say that you use oral therapy? Is that something that you typically will discuss with your patients? Or how about we back up? How about we talk about how you discuss with your patients the treatment options when they come in with plaque psoriasis, and where do oral options fit in in your algorithm?

Jayme Heim, MSN, FNP-BC: OK, well, I even have to back it up further.

Lauren Miller, MPAS, PA-C: OK, let’s do that.

Jayme Heim, MSN, FNP-BC: Because what happens is, a lot of times patients come in and they don’t understand the disease process, and it’s really hard. Patients nowadays, they want to know more. They want to be informed. And I remember my grandma, I’d say to her, “Grandma, why are you taking that?” [and she would say,] “Well, they told me to.” This is not the society we live in anymore. We want to know how much things cost. We want to know how they work. We want to understand why we’re doing what we’re doing. And we want to know [adverse] effects, and we want to know all of those things. So education is a huge portion of it. It’s amazing to me, even though people have Googled everything, the misperceptions that they have in relationship to [the] disease process. So I start by talking to them about their psoriasis and the disease itself, and what the disease is, what is the mechanism of action of the disease. And then I talk about the therapies because you have to understand the disease in order to understand why you’re using the therapy. And this is a chronic disease. It is not something that is like contact dermatitis, [where] we treat it and it goes away. This is something that is a more chronic disease, and it has comorbidities associated with.

Lauren Miller, MPAS, PA-C: I think patients assume, as with a lot of things, you should be able to fix this, and it should be able to be cured. Right. I try to [explain to] my patients, “Think of this as high blood pressure. Think of this as diabetes,” and things like that. Yes, we can get it better while you’re on therapy, but if you come off therapy, this is a disease that is still there, underlying.

Jayme Heim, MSN, FNP-BC: So, yes, literally, I look at them and I say, this is just a therapy. And I use the same example in regard to hypertension and diabetes and hyperlipidemia. I do the same thing. That is very important. Then I talk to the patients and ask them how they feel about it, and talk to them about the treatment options and everything. The one thing that does play a role in it is insurance. We have to deal with those insurances, and we have patients with chronic disease. So we have to decide, even if we feel that a patient wants to use an oral therapy and we have an access program, if this is the best way to go. So there’s some other decision-making that has to go along with that. But all in all, patients usually have a good idea, especially those patients who are needlephobic or feel that, for moderate to severe psoriasis, going to a medication that is an injectable therapy, they’re just not ready for that…in their lives. So I think that we have to look at all things and weigh them equally.

Transcript is AI-generated and edited for clarity and readability.