Stratifying Patients for Treatment With Biologics

Brad Glick, DO, MPH: Erin, how do you stratify patients in your practice for treatment with biologics?

Erin Boh, MD, PhD, FAAD: I look at a number of things, but high on my list is going to be comorbidities, and that’s 1 of the most important ones, because psoriasis as a disease has a number of comorbidities. They’re significant, so I look to see what comorbidities they have so that we can try to pick a drug that would impact both beneficially. That’s a very important 1. The other thing I like to look at are the prior treatments, especially with prior exposures to biologics, because the more biologics patients have been on, the less responsive they tend to be to newer agents. Even with the new IL-23s, we don’t have 100% clearance. There are people who do fail with these agents. That might go to George [Han]’s point about the genetics of psoriasis. We have 80-some odd…genetic permutations that we’ve seen that are barren in psoriasis, so not everybody has the same defect. It’s important to look at response to prior therapies when we try to pick our new agent.

Those are the ones I like to use the most. Primarily I’m at a tertiary care center, so I may get patients who’ve already failed with 4 biologics by the time they get to me. I need to know which have the best yield, or the best chance of working in patients who are biologically experienced. Then I can tailor that with the comorbidities, because we never want to give a patient a drug that will make a different disease worse. Those are the 2 that I look at the most. Third, we do have to be practical and consider, how is it going to be paid for? Patients who have no insurance are very lucky, in some regards, because I can get drugs from the various companies who are generous in giving drugs to patients without insurance, but patients with Medicare are quite limited in the drugs that they get. As we age with our patients, I’m finding this a more difficult situation that I’m put in. Patients are turning 65 years old and going on Medicare, and they’ve been on their biologic for 8 years, happy as a lark, clear of their psoriasis and their arthritis. Now I can’t get them drug. Those are the 3 most important factors that I look at when trying to pick a drug that will work. The biggest thing is, who’s going to pay for it?

Brad Glick, DO, MPH: Neal, your comments?

Neal Bhatia, MD: We could talk access all day, which is sad. Erin is right. If we can’t get them covered, we’re dead in the water. One thing I’ve found about the IL-23s is the flexibility with the dosage that draws patients in. I hate to call them the “healthy” walking-and-talking patients with psoriasis who have 10% surface area, because it sounds a little funny. But for the most part, there are a lot younger patients—they do have a lot of potential for comorbidities down the road, and I’m keeping a closer eye on them—but they tend to be that population that gets 6 doses a year, and they do well with it. I don’t worry about them in between, for a lot of them.

With tildrakizumab, we have to have a dosing strategy that’s either in office or at an infusion center, just because of the market dynamics. With guselkumab and risankizumab, you can have a little home use. I usually allow patients, once they’re on auto pilot—I tend not to hear from them while they’re on their IL-23s, which is a good thing—to home administer. I’d rather they spend their energy, their co-pays, and their time on getting better, but as I mentioned, I still have to have some breakthrough with a lot of these patients, whether it’s with calcipotriene, tazarotene, or some topical steroid. It just depends on what your preference is, but we need to find something that would be their breakthrough that they can start. If things are starting to change a little, then that may lead to class switching or changing things up, which we can talk about a little later.

Brad Glick, DO, MPH: That’s so well said, because the drugs are remarkable, but still, 50% to 60% of these patients will get 100% clear. To my math, that means 40% or 50% of the patients may need some additional therapies, as you say, and so it’s very important that we consider those collaborations as we look at patients in general.

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Transcripts edited for clarity.