Personalizing Treatment and Addressing Access Issues in Plaque Psoriasis

Lauren Miller, MPAS, PA-C: We’ve talked about this a little bit, but because now we have all of these options, we have numerous topicals, we have a few oral options, we have biologics now, [about] 12 or 13 on the market. How do you personalize a treatment plan for a patient with all of the options? And I preface that with saying personally what I’ve had to kind of do over time is pick my favorites. And maybe every class I typically have 1 or 2 favorite topicals. I have 1 or 2 favorite systemic therapies, orals, and then I have a favorite maybe in each biologic class. How do you streamline your approach when there are so many and we only have so much time in that patient visit to discuss the options?

Jayme Heim, MSN, FNP-BC: I think I do that too. The one element of it is those patients on Medicare. So they’re also carved out as: How do I get them here? So, unless they have patient assistance programs that they can qualify for, or if it’s an in-office injectable or an infusion that falls under their medical instead of their pharmacy, because that’s really important for Medicare patients. I really have a hard time understanding how people can work hard all their life and then have to go on Medicare or they retire. And then it’s not that their psoriasis goes away. They still have their psoriasis. So when I look at options for care, I have to, and I often say to the companies themselves, “What are you doing to help Medicare patients? So that also there is an IL-23 that is through one or the other with one of the companies that also has a TNF [tumor necrosis factor] with their IL-23 we have access for Medicare patients. We have another IL-23 that’s an in-office injection, or the insurance company requires them to go to an infusion center. There also is an infusion of usable medication, which has become very difficult to do through the insurances. Lots of times they go ahead and say that there’s coverage, but it’s not because the amount that is expected for the patient to pick up for responsibility is not feasible at all. The people who really get stuck in the middle are the people who have worked all their life and haven’t relied on society and haven’t saved yet. They can’t afford to buy these medications out of pocket every month. And they have horrific psoriasis. So there are just those patients who don’t have treatment. They just go back to having severe psoriasis and not even moderate psoriasis.

Lauren Miller, MPAS, PA-C: So would you say that that’s one of the biggest barriers right now in plaque psoriasis treatment, chronic disease treatment? I would say that probably one of the biggest hurdles and obstacles is access to the medications.

Jayme Heim, MSN, FNP-BC: Oh, absolutely. In in our state of Michigan, even with Medicaid, you have much more access right away to appropriate therapy than you do if you have commercial insurance. And insurance does dictate, like we talked about, even doing DMARDs [disease-modifying antirheumatic drugs] before. You know, once they’ve done the DMARDs and they’ve failed the DMARDs because they’re just not as efficacious, or else they start developing problems with lab abnormalities or with cyclosporine, their blood pressure is shooting through the roof besides lab abnormalities. And with cyclosporine itself, it’s not a long-term medication anyway. It’s a short-term medication. It’s just a bridge. I just call those stopping blocks for the insurance companies. Once we’ve gotten past that, it’s like opening up the Golden Gate. But for Medicare, it’s not the same. With even with pediatric care. We have more now for pediatric care for psoriasis, which is wonderful. But I see that there is 1 really specific population that really is just not getting the care that they need. As far as the other, oral medicines are not appropriate for all people. We do a tremendous amount when we work with patients with psoriasis and their medications. We make sure that they’re going to be safe for patients. I know you probably have patients come to you and they’ve had histories of cancer. They’ve had solid tumors. What are you going to put them on? Well, you know, you work along with an oncologist, but usually it’s IL-23. IL-23s are always acceptable, and they usually work pretty well for those patients. So that’s why in those cases, it really has to be individualized. We have to have a tremendous amount of education [and] knowledge when dealing with these medications. This is not something that we do haphazardly at all when we do this. We are truly professionals in what we do, and we truly do specialize in that. The one thing is that if you don’t know how to treat patients with psoriasis and they need medications in mild to severe psoriasis, to try this alone is not going to do it. Please have the compassion enough to send those patients to somebody who can treat them. I hate it when I have a patient in front of me who says, “If you can’t help me with this, I’m done.” And they mean it.

Lauren Miller, MPAS, PA-C: Because they’ve had so many [health care] providers.

Jayme Heim, MSN, FNP-BC: Yes. That physically they’re going to take their own life. I had a patient who came back and said to me, “It’s your birthday today too.” And I said, “Why?” He said, “Because when I came to see you on my birthday, if I wasn’t clear by my following birthday, I was going to kill myself.” So, you know, I don’t want to see that ever happen. But we need to recognize also as APPs [advanced practice providers] in dermatology, if you don’t specialize in this, send these patients to somebody who does. It is not a cookie-cutter approach, and you do need to continue to educate yourself and to educate your patients.

Lauren Miller, MPAS, PA-C: I look at it kind of as a puzzle, essentially, and there are so many pieces. How old is the patient? Are we talking about an adolescent or an adult? Because that’s going to put us in a bucket of treatment options. Do they have signs or risk factors for psoriatic arthritis? Because then that’s going to put us in a bucket of options. What other comorbidities do they have? And we know a lot of times these patients have heart disease, they have obesity and other things, high cholesterol, things of that nature that we know that these systemic options can help, where topical therapies we know unfortunately can’t help with those comorbidities. But I agree with you, there is no cookie-cutter approach. You literally have to sit down and look at that patient’s story and kind of put together this picture in this puzzle. And it’s just really cool that we had only a few options that we could utilize when we started. And now we have so many that the problem is we don’t have enough time in our visit to do it, so we’re having to actually have the conversation of how we streamline our office visit. That’s our biggest problem, how we streamline our office visit because we have so many options that we’re able to provide for the patients to get them where they want to be and where we want them to be. If that’s our worst [and] biggest obstacle—how do we strengthen our office visit and get them all of the information they need in that office visit—then I think we’re doing pretty good.

Jayme Heim, MSN, FNP-BC: So one of the other big parts of that puzzle is women in childbearing years, because there are a lot of younger people who are female who do have moderate to severe psoriasis. Then we look at specific[s]; the years that they’ve had disease, or do they have nail and scalp disease? Are they going to be at increased risk for severe arthritis because of [having] a chronic disease? We need to think of their overall health and, you know, decreasing those comorbidities as they move forward in life too.

Lauren Miller, MPAS, PA-C: We’re treating that. We’re treating the patient as a whole and not just their skin.

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