Treatment Selection of Biologics and Oral Therapies in Plaque Psoriasis

Lauren Miller, MPAS, PA-C: So how do you go about deciding between an oral option and a biologic? Would you say that it’s like what you said—it just kind of depends on a multitude of things? I know I take into account location of disease, obviously age. But the biggest thing is you have to ask the patient, “Are you willing to inject?” I mean, that’s No. 1. If they’re not willing to inject…. I live in a more rural area, which I think you do as well, [and] I have a lot of truck drivers or people who travel for work and they’re not able to carry their injections with them. So, depending on their lifestyle, biologic therapy may not be feasible. And so oral therapy is often a good option. So how do you decide the other things that you take into account when you’re trying to decide between oral and biologic therapy and, as you mentioned earlier, about the patient and educating them? I know it’s very much about shared decision-making. Talk to me a little bit about that.

Jayme Heim, MSN, FNP-BC: Well, for one thing, with the oral medication, as we discussed previously, some people just do not want to do an injectable. Even when you talk to them about coming into the office. Because there are we do have some injectables that do have an option…for an in-office injection. And they just do not feel comfortable with that at all. They have just set in their mind that that is just not a therapy that they are willing to do at all. So, if appropriate, this is a wonderful option that we have for patients, being that it’s an appropriate medication for the patient themselves. I think that as far as orals go, in general, unfortunately, I go back to insurances too. A lot of times you can, with deucravacitinib—there is a program where they can get access to the medication and they can literally get access up to 3 years if their insurance company does not go ahead and put it on formulary. And…I would love to see it placed as DMARD [disease-modifying antirheumatic drug]. I really would. I would just feel much more comfortable treating my patients with this medication than I do. And having to look at medications like methotrexate.

Lauren Miller, MPAS, PA-C: I agree 100%.

Jayme Heim, MSN, FNP-BC: Cyclosporin, acetretin…and when you look at women in childbearing years, you look at a lot of the other comorbidity factors, and I would really love to see it in the demand start-up.

Lauren Miller, MPAS, PA-C: Well, those require routine lab monitoring, which again, takes us to No. 1, it’s not convenient, but No. 2, that takes us back to patients who have an aversion to needles. They’re having to go and get that routine lab monitoring. And…we don’t have that need for the frequency of the routine lab monitoring that we do with those other older standard therapies.

Jayme Heim, MSN, FNP-BC:Absolutely. And not only that, we were talking about…how it’s very specific. And really, when you’re looking at these other medications that are used as DMARDs, it’s just like looking at a shotgun approach. And it is not a direct therapy. It is literally affecting all these other areas of the body, and it just increases patients’ risk. And it’s really unfortunate that in this day and age that we have to, lots of times, even utilize these therapies because patients do not get access unless they do. Now, when I talk about access and a lot of people say, “Oh, we have an early-access program,” I have to always think about the fact that patients have a chronic disease. So I’m not just looking at 2 or 3 years. I’m looking at their overall treatment, their physical, their psychological well-being. They’re there. They’re decreasing their risk for comorbidities in the future by treating their psoriasis. And so it’s horrible because we’ve had these programs, and we utilize these programs. But then once it comes to an end, if those medications are not on formulary with insurances, patients [are] literally…even…watching it. It’s like a clock ticking down. You know what—it’s going to end. It’s going to end like next year. What’s going to happen next year? It’s going to end in 6 months. What’s going to happen in 6 months? They’re scared. And…that’s really hard to see patients scared like that. I would love to see this molecule put on formulary. I would love to see it used as a DMARD status. And that’s how I would like to see it positioned.

Lauren Miller, MPAS, PA-C: Would you say that you use deucravacitinib and apremilast? You use those first line if access and insurance coverage aren’t an option?

Jayme Heim, MSN, FNP-BC: To tell you the truth, deucravacitinib, I would use that more than apremilast just because the weight loss is real too, with apremilast. And that’s not because the people said, “Oh, well, it’s probably because of patients’ diarrhea and the nausea they have.” It’s not. The patients I have had…are men and women…it’s just unbelievable. They just decrease eating significantly. Their food doesn’t taste the same. They don’t have a drive for an appetite. And it’s not because they have nausea, it’s not because they have headache, it’s not because they have diarrhea. And so it’s very interesting. I just haven’t seen those types of [adverse] effects with deucravacitinib. I haven’t seen it, and the efficacy is higher.

Lauren Miller, MPAS, PA-C: So have you seen any other [adverse] effects with deucravacitinib that maybe you didn’t see with apremilast?

Jayme Heim, MSN, FNP-BC: Not really because the only other thing is just that it doesn’t work for the patient. Just not getting the efficacy from the medication that we want. And like you mentioned earlier, this is not a medication that’s really FDA approved at this point for psoriatic arthritis. So those patients…I wouldn’t go ahead and put a patient who had active known psoriatic arthritis on this medication.

Lauren Miller, MPAS, PA-C: Right. I do love right now that they have—because they are still relatively new to market—the 1-month pack that patients are able to go ahead and start on. And my patients get really excited when they’re in the office. And I say once we do the screening that we need to do, here’s 1 month to get you started. That gives us some time to go through any paperwork. But typically I haven’t had any issues as far as the paperwork and getting it approved and them running out of their starter pack before we’ve gotten the approval in. I was going to ask you how often you typically see your patients, oral therapy wise, because we know there is a little bit slower onset before they’re going to see that drastic improvement. How often, and when do you do that? First follow-up and maybe that second follow-up?

Jayme Heim, MSN, FNP-BC: I like to do the first follow-up in 8 weeks because I really don’t anticipate seeing much prior to 8 weeks. At least at 8 weeks, they should be seeing a little bit, they should be seeing at least a decrease in the scaling that they have. The color also is not more of the red but more of a pink color. Their itching is also decreased, which is really important, too, because with these 2 medications, you see a decrease in the itching and itch is really important. In fact, from Greek the psori means “to itch.” Whereas a long time ago, we used to think that psoriasis didn’t itch, only atopic dermatitis itched, but that very first part of that word in Greek means “to itch.”

Lauren Miller, MPAS, PA-C: I agree with you on that. I typically will do a 6- to 8-week [follow-up], and it’s mostly to kind of check in and ensure that they haven’t fallen off the train, that they’re still taking their medication, they haven’t had any kind of adverse event and decided that they were going to stop therapy on their own. And just help again remind them [to] manage those expectations. And then typically I’m doing a 3-month total follow-up. And by that point, I really feel like we’re seeing whether or not this is something that’s going to be something that we’re going to utilize longer down the road.

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