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Approved Medications for GPP


Aaron Farberg, MD, reviews medications that are approved to treat generalized pustular psoriasis and the potential role of combination therapy.

Ryan Haumschild, PharmD, MS, MBA: Let’s talk about the evolving treatment landscape of generalized pustular psoriasis [GPP]. Maybe we can discuss some of the current and evolving treatments of the disease, including topical management, and how we manage acute events, as well as some of the decision-making we have within the clinic or the inpatient setting when we’re treating these patients. Dr Farberg, I’d like to start with you. Maybe you could give us a general overview. What are the medications available approved to treat GPP, and how are patients with GPP being treated? Because I know there are some oral retinoids that we’ve talked about, methotrexate, biologics, and then maybe tell us, are you using any combination therapy?

Aaron Farberg, MD: I want to give credit to the only medication that’s actually approved for GPP and that’s spesolimab, the IL-36 [interleukin-36] blocker. It’s the first and only to be approved for GPP, so it should be at the front of the list and should be what we’re all thinking about when you hear the diagnosis of GPP. As Dr Lebwohl had mentioned, it’s given as an infusion, but hopefully in the near future as we look ahead, it will be offered as a subcutaneous dosing, and we’re still trying to figure out the best way to prevent flares with it. How often do we give it after we utilize the medication for the first onset or the acute flare? When it comes to other treatments, thankfully many of these came before even I was in residency. You have things such as acitretin, which is an oral retinoid, as well as methotrexate. Cyclosporin is an immunosuppressant drug that is often used early and initially because it works so quickly, but those have been overtaken by the biologics. TNFs [tumor necrosis factor blockers], as Dr Lebwohl mentioned earlier, I like to go toward the IL-17 biologic medications because they do work so quickly, and oftentimes, we do have them available. We are utilizing IL-17 and IL-23 blockers.

The issue, as you’re understanding with the variety of different treatment options we have, is that’s not necessarily a good thing because if there was one that worked so much better, then that would be the one we would all use, and that is the one that is approved, spesolimab. Again, if we could reverse to just a few months ago before we had that, it was oftentimes whichever medication we could get ahold of. That comes back to the availability, whether it is simply having the medication available or an insurance company issue. It’s a complex environment as to which treatment options we choose, but we have to look at the patient and decide what’s going to be best for them. If it truly is that severe, walking into the emergency department–type patient, then you’re going to go for spesolimab, or you’re going to try to grab one of those IL17 or 23s that hopefully, you have in your fridge as well.

If it’s a more mild or chronic sort of smoldering disease, then perhaps you can consider some of the topical treatments, or perhaps even some of the other pills as well, such as an oral retinoid. It’s good as clinicians to have a variety of options, and a variety of tools in our toolbox to treat patients because as you also asked, do you combine any of these? Absolutely, we combine medications because no treatment is going to work 100% of the time. You have to talk with and understand your patient, what their needs are and how they’re doing on their therapy. Sometimes you have to modulate and add various treatments that work best for them.

Ryan Haumschild, PharmD, MS, MBA: Thanks for giving us that overview. As you said, some agents have been around for a long time, but now it sounds like a lot more efficacious agents are coming to the market, providing a lot of disease relief. It is something we should all be very aware of, especially as we’re trying to care for these patients, not only the disease, but also the adverse effects that can be associated with some of these immunomodulating agents.

Transcript edited for clarity.

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