Peter L. Salgo, MD: In order for the drug to work, patients have to take the treatment, which brings us to patient adherence, right? What is the state of patient adherence in regard to these drugs? You’ve got payer data, you’ve got patient data, what are we looking at?

Steven Feldman, MD, PhD: Think about it for a moment. If you have this horrible disabling disease, and you give somebody a shot, all they’ve got to do is take it once every 2 weeks—they’re going to take it, right? No, don’t be naïve. They’re not going to do it.

Peter L. Salgo, MD: I was about to say, no.

Steven Feldman, MD, PhD: All you’ve got to do is ask them: “Are you keeping the extras that you’ve accumulated refrigerated like you’re supposed to?” And of course if they’re taken the way they’re supposed to, they won’t have any extras. It’s rare to have a patient say, “I don’t know what you’re talking about, I don’t have any extras.”

Peter L. Salgo, MD: You know you are a sly guy. I’ll bet you do magic in your spare time because that’s a tricky question.

Steven Feldman, MD, PhD: I’ve started by doing studies with creams because I want to know if the people are putting their creams on. I got a hold of some of those medication bottle caps that contain computer chips that would record the day and time people open and close the containers. And you could see psoriasis patients use their cream less over time.

But I wanted to know what they did with their biologic. How are you going to stick the thing on? What we did is we got these Clorox bleach bottles and slapped a biohazard label on them, put the computer chip cap on top, and told patients: “Take your shot every 2 weeks, throw it away in this container, keep it sealed up real well, bring it back to us, we’ll dispose of them properly.”

Peter L. Salgo, MD: You’re still being sly.

Steven Feldman, MD, PhD: It was a tiny little study and half the patients used it pretty well, and then half the patients for this every 2-week drug would go a month, 6 weeks, 8 weeks, 3 months, between dosing. So yes, their adherence is absolutely terrible. And I think the insurer probably can disclose some global data, but all they know is whether the drug was shipped or not. They don’t know whether they actually took it.

Peter Dehnel, MD: Patient adherence or compliance—whichever term you want to use—is extremely important from the insurer’s standpoint. The most expensive drug, as you’ve heard before, is the one that’s not given. And so the question is, what can be done, from an insurer’s standpoint, to help support and ensure compliance with whatever regimen is being used? If they have to come in every 2 weeks, that’s inconvenient. If they have to come in every 3 months, they may forget it. I think that this is a great opportunity to work on an area of compliance, something that can physically show the efficacy.

Joel Gelfand, MD, MSCE, FAAD: Yes, that’s a great question, how can we partner up and make treatment more successful for patients. I think that it has to be studied, to try understanding it from a patient’s perspective; why are they delaying their dose? I hear from some of my patients who get into those behaviors, that a lot of it is about how they’re afraid of losing access to the therapy, and they’re sort of stockpiling it.

Steven Feldman, MD, PhD: Back in 2008 and 2009, when people were worried about losing their jobs and their insurance, I think that was a very common phenomenon. But I think doctors are horrible about getting people to take their medicine.

If you look at a typical drug study, they bring people back at weeks 1, 2, 4, 6, 8, and they show this nice improvement. And then dermatologists say, “Well, in 8 to 12 weeks you do well, so I’ll see you back in 8 to 12 weeks,” and they don’t have those visits at weeks 1, 2, 4, 5, 6.

If a piano teacher said to you: “We don’t need weekly lessons, just practice every day. I’ll see you at the recital in 2 to 3 months,” everybody knows that recital would sound horrible. I have the most hardworking, industrious, motivated people working for me, doing research with me—medical students who want to become dermatologist residents. I don’t, at the beginning of the summer, hand them a project and say, “Work on this, I’ll meet with you again at the end of the summer.” I have a laboratory meeting with them every week, which drives their behavior. This idea, that you could tell a human: “Here, do this, see you in 3 months,” is ridiculous at its face, and ironically, the fact that anybody’s using their medicine at all, when we have that kind of arrangement, is actually more surprising—not that people aren’t taking their medicines.

Peter L. Salgo, MD: One of the famous studies gave medical students placebos and said, “Take 1 pill a day, every day,” and gave them 365 pills. “Bring back the pill jar at the end of the year.” There were about 30% leftover pills, on average. And these were people who had no adverse effects, of course, and no obvious benefit—but no adverse effects. A third of the pills were untaken. What do you do with that?

Steven Feldman, MD, PhD: If they didn’t have computer chips reporting their daily use, it may be that a lot of those pills ended up in a parking lot somewhere where they were dumped out.

Peter L. Salgo, MD: So you think it’s even higher than 30%.

Steven Feldman, MD, PhD: Adherence? Oh, gosh. Listen, I would never label somebody as a noncompliant patient, that would be wrong, because it’s redundant.

Peter L. Salgo, MD: But by the same token, you said that we do a terrible job.

Steven Feldman, MD, PhD: It’s all our fault.

Peter L. Salgo, MD: But isn’t it just human beings are terrible at taking pills?

Steven Feldman, MD, PhD: Yes, absolutely.

Peter L. Salgo, MD: Or taking injections.

Steven Feldman, MD, PhD: A doctor’s responsibility is to get the patient well. Our responsibility is not to make the right diagnosis and prescribe the right treatment, but to make people well. And sure, it sounds like we want to partner in that. To get people well you have to make the right diagnosis, prescribe the right therapy, and get the patient to do it. If you do it in the office with injections every 3 months, OK, then you can control a lot of the barriers.