Use of Step Therapy in Treatment of Plaque Psoriasis

Alexa Hetzel, MS, PA-C: Darren, in your experience, do patients have to fail certain therapies for APPs [advance practice providers] to utilize step-up treatment approaches?

Darren West, MPAS, PA-C: For the most part, kind of, yes. It’s a loaded question because I have a lot of patients who have been on so many drugs, but with the advancement of all these newer medications, companies have found ways in which we can step through hoops a little bit easier now. So I think that in today’s climate, yes, you want to have a couple of failures.

It’s very important that we also have biologic coordinators...who guide us along the way. We need to have everything in order, and all of us who have been writing prescriptions for biologics for many years know that we do have to have documentation of everything that we are doing and anything that we have tried. But, yes, we want to see patients have tried topical therapy, we want to see that they’ve tried some oral therapy.

My hope is that, in some instances, we don’t have to do the orals anymore. I’m seeing that more and more that we don’t have to see the failures on some of the oral medications and the DMARDs [disease-modifying antirheumatic drugs] because, to be honest, I’m hoping that those are going by the wayside now. I’ve been able to get a lot of patients on medications with just being on topicals and who may be at high risk to doing the DMARDs.

So, for me, yeah, you have to fail some products. You have to be on topical steroids, you have to be on calcipotriene, vitamin B3 analogs. You’ve got to do some of those steps for sure. Maybe phototherapy. These things that we’ve been traditionally doing that have been going on for years.

Then I’ll go straight into biologics. If it’s bad enough, if their BSA [body surface area] is at least 10% on their body or if they have, to Andrea’s point, groin or scalp psoriasis, or even hand or foot psoriasis of 1,% 2%, 3%, that’s all it takes, and we’re jumping through and getting this covered on some of these biologics. I try to get them on quick. I don’t try to let a lot of stuff block us. It really depends on our biologic coordinators and how well they can put the paperwork together for us and appeals and things of that nature. Not too many failures but a little bit.

Alexa Hetzel, MS, PA-C: Do you feel like in clinical practice you notice a decrease in treatment failure as we’ve gotten a little bit more specific, a little bit better in treatment options for patients?

Darren West, MPAS, PA-C: I think it’s getting to be less treatment failure. I think with what we’ve got today, I hardly have to change my patient to a different biologic too often. But again, we don’t know what biologic is better for the patient until we’ve tried it. Honestly, most of the biologics that we start on are pretty good. The last 3 to 4 years, the newer biologics, the IL-23s, the IL-17s, those have pretty much been a slam dunk for most of us. Now granted, if they fail... And again, we don’t know who’s going to fail on a product, but I haven’t seen a whole lot of failures within the last 2 or 3 years. When I send my patient out the door, I give them a shot and tell them this is the process: 9 times out of 10, they’re not coming back complaining that it’s flaring. They’re coming back because they need a refill. We lose track of these patients a little bit because of that.

Alexa Hetzel, MS, PA-C: What are some reasons that you see for patients who maybe are just on topical agents with moderate to severe disease that are failing these topical agents?

Darren West, MPAS, PA-C: I think for the people who just do topical therapy, it’s just the burden of having to put something on their skin a lot. I think they’re kind of over it. Most of my patients who have only topical therapy, they may not even care too much. My patient might think his skin is OK, but I look at it and think they need help. We’re critical when it comes to our patients because we want perfection. But our patients who are using these creams, I think they’re just over it, and they don’t always know there’s something out there on the market that could actually help them any better. So I’m always amazed at our patients that only have topical therapy and only want to do topical therapy when we have so much going on, but I guess it really honestly depends upon our patient’s desire to improve their quality of life. Everyone’s different, but once in a while somebody just doesn’t care. So that is kind of interesting.

Alexa Hetzel, MS, PA-C: So simply put.

Darren West, MPAS, PA-C: I know.

Alexa Hetzel, MS, PA-C: It’s true though. It’s totally true.

Transcript edited for clarity