Role of Advanced Practice Providers and Pharmacists in Managing Plaque Psoriasis

Alexa Hetzel,MS, PA-C: Hello, and welcome to this HCPLive® Peer Exchange titled “Advances and Unmet Needs in the Management of Plaque Psoriasis: Expert Advanced Provider Perspectives”. I am Alexa Hetzel, a physician assistant [PA] at Windsor Dermatology in East Windsor, New Jersey. Joining me today in this discussion are my colleagues, Douglas DiRuggiero, a physician assistant at the skin center and cosmetic dermatology centers in Rome and Cartersville Georgia, Jayme Heim, a family nurse practitioner [NP] at West Michigan Dermatology in Grandville, Michigan, Andrea Nguyen, a physician assistant at First OC Dermatology at Irvine, California, and Darren West, a physician assistant at Spectrum Dermatology in Scottsdale, Arizona. Our discussion today will focus on several topics pertaining to the treatment landscape for the management of plaque psoriasis. We will review available and emerging treatment options, highlighting recent approvals and long-term safety and efficacy data for these treatments. Welcome, everyone. Let’s get started. Douglas, who is typically diagnosing and managing patients with plaque psoriasis?

Douglas DiRuggiero, DMSc, PA-C: I just want to, first of all, say I’m honored to be here, and what a great group of people to assemble. I’m particularly interested in hearing everyone’s opinion from different parts of the country. If you're going to ask who’s typically diagnosing this, it’s kind of a double-edged question because I think a lot of studies say that still, the folks in the family care world, or family doctors and pediatricians, are the ones seeing these patients with psoriasis first line. Since biologics have come into our landscape over the last 15 to 20 years, companies have done a very good job of getting the word out about what psoriasis is, advertising, commercials, and we’re seeing more and more patients being driven into our office, and more and more primary care individuals wanting to deliver these patients to us. So yes, I think that psoriasis is a cutaneous manifestation of a systemic disease, but it manifests in the skin primarily. I know some folks can manifest the joints first, but that’s the minority. Since it is a cutaneous disease, it should be managed by folks who are experts in taking care of the skin, and we’re all trying to be that. And so, it falls squarely on us, and us being dermatologic providers.

Now, the reality is that nurse practitioners and PAs are doing more and more medical dermatology as we enter the space. We have approximately 4000 to 5000 PAs practicing fulltime dermatology, 4000 to 5000 NPs, so we have a group combined that's between 9000 and 10,000 that are practicing for board certified and board eligible dermatologists right now. That is allowing our collaborative physicians, some of them who love it are staying squarely in the medical dermatology space, and others are taking advantage of cosmetics and surgery in other areas. So, we’re seeing that this is our bread and butter. This is what we were trained to do, to take care of the patient. This is a disease that we know has comorbidities, and has a lot of other questions we need to ask. A lot of time we need to slow down and get a good review of systems to be able to find out the right treatment and the right therapy. This is what we were trained to do in primary care, to focus on the whole patient. This is a very nice dovetailing of the training of an advanced practiced clinical practitioner like an NP and PA to be able to manage a disease like psoriasis and other immune-driven diseases that we see in our clinic.

Alexa Hetzel,MS, PA-C: How do you feel like the role of pharmacists play into the management of our patients with plaque psoriasis?

Douglas DiRuggiero, DMSc, PA-C: Gosh, every time I walk into a room, there’s an invisible pharmacist that’s sitting in the corner, an invisible insurance adjuster, and invisible lawyer. All these people are in the room with you. But the pharmacist plays a huge role, because once the prescription leaves our office, it goes into the pharmacy world. Of course we have third-party vendors that help try to manage and negotiate getting the patient on the medication that the prescriber wants to have. So the pharmacist has a huge role. The pharmacist historically has always had a huge role on continuing the education of patients about medications.

Pharmacists call back and say, “Did you realize they’re on this medication and what you’re prescribing may be contraindicated?” Oof, thank you so much. So, I’m very pro-pharmacist in terms of the role they play, the education they have. Super smart people that have a very big impact, but they also have an impact on controlling what’s happening. It’s a marriage between the insurance formulary and the pharmacist. So, we do have a give and take, a love/hate that happens sometimes, with us wanting to get patients on certain medications, but formularies not wanting to have it happen. And so, I view our pharmacists as tremendous allies for us and as tremendous help, but overall, they’re the ones that are the gatekeepers on us getting people onto the medications that we feel is appropriate based on their comorbidities, their past failed therapies and the things that we feel like is going to help them the most for the type of presentation that they have.

Alexa Hetzel,MS, PA-C: Another team player. I love it.

Transcript edited for clarity