A Personalized Approach to Disease Management in Psoriasis - Episode 10

Designing Appropriate Treatment Regimens for Patients With Psoriasis and MetS

Drs Lebwohl and Groves comment on what they factor in when deciding to switch agents and provide targeted treatments for psoriasis and metabolic syndrome.

Ryan Haumschild, PharmD, MS, MBA: We’ve talked about this switching of agents, and it makes sense to target some of these patients. What does that look like for psoriasis and metabolic syndrome? And what do you think of this idea of creating a pathway for this patient population to get access to certain medications that have better data earlier on instead of taking more of that overarching approach that everyone starts one therapy first, and then has to transition through subsequent therapies till they’re ultimately meeting maybe, let’s say, an IL-23 [interleukin-23] or an IL-17 that has better data? I’m curious, I’d like to open it up, maybe Dr Lebwohl, you chime in, and then Dr Groves, I’d love to hear some of your key considerations.

Mark Lebwohl, MD: I will say that my goals are perhaps different than yours in that I’m always looking for a drug that first of all is very safe and very effective, and that takes a little priority over costs. But once we have drugs and we have several that are very safe and very effective, I’m not going to fight to go from one to another if an insurance company finds it advantageous for me to give drug A versus drug B when they’re very similar. I will say you mentioned tildrakizumab, which is a drug I use a lot. One of the biggest advantages for my patients is that because it’s always a medical benefit, it’s always easily covered. If patients have Medicare and a coinsurance, that pays for it completely; if they have Medicare and Medicaid, that pays for it completely. If they have commercial insurance, some of that advantage is taken away because the commercial insurers often will allow me to pick any of these drugs, all of which are too expensive, and they’ll pay the difference. But certainly, for Medicare patients, I’m kind of stuck. I have to use tildrakizumab. And again, it was a disadvantage of when the trials for tildrakizumab were done, they were done by Merck, which didn’t really know, they were not a dermatology company. They didn’t know what they were doing in the space.

Thus, here’s a drug where you see the peak effect is actually at 7 months. If you look at the curves of efficacy for tildrakizumab, it actually does not peak until 7 months, but they picked as the primary end point week 12. Most of the other drugs learned from that, and they picked week 16, at least closer to that delayed peak. And a lot of those drugs also are a little faster, so they do indeed peak around week 16; their data were quite good at week 16. Tildrakizumab does not peak until 7 months, so week 28. But at week 28, it peaks, and the durability of response is extraordinary. When you stop tildrakizumab, those patients remain clear. The median time to recurrence with the 100-mg dose was 224 days, so those patients really stay clear for a long time.

Certainly, in the population of patients who are not Medicare-enrolled who are obese and have metabolic syndrome, I’m going to go usually to an IL-17 or IL-23 blocker. For the patients who have Medicare, the 2 good options for me are an IL-23 blocker, or infliximab is given in milligrams per kilogram. Ustekinumab is also dose adjusted, and those 3 can be given to a Medicare population. Ustekinumab is less effective than tildrakizumab is at its 7-month point, although at its 12-week point, they’re similar. Infliximab is very effective, but has the boxed warnings, which is why I don’t like to use it. Thus, for the Medicare population, tildrakizumab is an excellent choice.

Robert Groves, MD: I don’t have, and never will have the depth of knowledge, Dr Lebwohl, that you do in this particular space, but from a broader perspective, let’s take a step back and look at the whole picture. This is what I call a knowledge management problem. The reason that we have not gotten more specific is because either, one, that level of evidence doesn’t yet exist in a reproducible fashion, so more than just 1 laboratory has validated the outcome, and in part because there are only so many studies you can do, and there are a lot of things to study. Shifting from the knowledge management system we have today, which is call Dr Lebwohl and see what he says, and he can’t take everybody’s call, to something that puts that information in front of practicing physicians in real time, is part of that holy grail, if you will, of really getting this right.

The other thing that I would say is when we talk about equity, we also have to talk about the fact that this is one disease entity. About 3% of the population is exposed to biologics, whereas 40% of pharmacy costs are attributed to biologics, so there’s a real imbalance there in terms of if these resources aren’t available to this patient, or if they are available to this patient, they’re not available to that patient. We still have limited resources, and so we have to take that view. As a practicing physician, you can’t really. You’ve got the patient in front of you, and you got to do the very best you can to make the right choice for that patient. But these are solvable problems. We now have the computing power and the ability to begin solving these problems.

It’s a shift from what my mentor and boss John Hensing, [MD,] used to call including with evidence-based practice, practice-based evidence. In other words, we need to do a much better job at capturing the information that we get from every patient encounter, and then using that to understand and learn more about our patient populations and how we might tailor therapy. What that requires is something more than looking at what the drug costs, and that has historically been the focus for obvious reasons, 18% of GDP [gross domestic product], etc. Thus, it is a complex problem. My bias is that we will solve these problems once we get rid of what are really perverse incentives that pit physician against payer, that pit patient against payer. Once we get past those kinds of incentives that haven’t served us well in at least a couple of decades, then I think we have a real chance of getting to best practice. In the current environment, it’s tough, but I applaud the effort, Ryan, in trying to get us there.

The more evidence that we have, the better, the easier it is for me to talk to a committee about what I think we should be covering and why, so the more evidence the better. But we’ve got to do a much better job of having a real 360-degree view of our patients, being able to collate all of those data in one place. You look in the Phoenix market, loyalty is about 50%. If you look at the average patient in the Phoenix market, they will spend 50% of their time in 1 organization. The rest of their time, maybe for other diagnoses, they’re going to a different organization. They have different EMRs [electronic medical records], they have different processes, and all of those fragmented data need to be brought together in 1 place so that we can have reliable practice-based evidence to help guide what researchers like Dr Lebwohl look at. We need to see if we can find clues to what ought to be studied in a rigorous way to answer the question, is this association or causality? Thus, I think we’ve got some work to do, but we now have the computing power to do it. There’s really no excuse for not advancing the field. And I applaud the effort that you’re describing.

This transcript has been edited for clarity.