Panelists discuss the impact of dosing schedules on patient adherence and preference.
Peter L. Salgo, MD: Is it better, in terms of adherence, if you have to go to a doctor’s office to get the shot, or to get the drug?
Steven Feldman, MD, PhD: Yes.
Joel Gelfand, MD, MSCE, FAAD: Well, I think that we’ll know that they’re taking the medication. I think that one of the challenges in our population is that many patients want to come into the office to have their subcutaneous shot done by our staff, even though they’re labeled for home use. There’s not a system set up to support that. Insurers don’t pay for that service, for example. It can be quite burdensome for a clinical practice to manage that for their patients when you have a busy practice.
Steven Feldman, MD, PhD: If you do it in the office, you not only know that they actually got the shot, you know that they’re using it properly. If you just educate people to take the drug company’s sample injector device and an orange, and you show people how to do it—you push the button, you hold it there, you wait till it all goes in, then you take it off. At least in North Carolina, they may stop at the Piggly Wiggly or another grocery store on the way home and buy oranges, and then take that medicine and inject it into the orange thinking that that’s what you wanted them to do.
We’ve heard about people whose Humira needles, their adalimumab, a self-injected medicine, would bend when they gave themselves the shot because they were being given it for scalp psoriasis, and they were injecting it into their skull. I don’t know how long the patient leaves the medicine on their porch before they bring it in the house. I don’t know if they’re told, “refrigerate, don’t freeze,” but by the time they get home they may say, “She said something about refrigeration and freezing. If refrigeration is good, freezing must be much better.” Or they put it in their refrigerator, in the back of the refrigerator by the coils, where the stuff freezes. I don’t know what happens when you have people administer medication on their own. Doing it in the office gets rid of a lot of other issues.
I’m gathering that these new drugs can be injected at home. Do some of them require doctors’ visits? Is there a distinction here?
Joel Gelfand, MD, MSCE, FAAD: Most of them will be subcutaneously administered at home. They don’t necessarily have to come in the office for it. So for us it’s mainly only people with needle phobias.
Steven Feldman, MD, PhD: One drug, tildrakizumab, is approved only for in-office.
Peter L. Salgo, MD: Why is that?
Steven Feldman, MD, PhD: I suspect because in the studies, it was done in the office. And because it was done in the office in the studies, the FDA approval was for in-office use.
Peter L. Salgo, MD: Now we can generate constructs, right, which make either way look good. If you’re going to give it at home, it’s convenient, you can do it, you don’t have to take an afternoon off from work, you don’t have to wait in the doctor’s office and pay the bill—you can just do it. On the other hand, they won’t do it. And maybe coming to the doctor’s office is the preferred way. Should all of these things be done in the doctor’s office?
Steven Feldman, MD, PhD: No, different strokes for different folks. Sometimes, it’s better to have it at home. I’ve got patients driving a long way to see me, it would be a lot to ask them for an every-2-week drug to be doing it in the office. The other thing that’s nice from a practical standpoint about having office administered versus at home is at home, this falls under the pharmacy benefit. In-office might fall under medical benefit. And in some patients’ plans an at-home pharmacy benefit might have a much higher co-pay than in-office, and there could be some additional advantages from in-office treatment.
Peter L. Salgo, MD: And some of these drugs have, as you implied, long intervals between doses, right? Anywhere from what, 2 weeks to months?
Joel Gelfand, MD, MSCE, FAAD: To 3 months.
Peter L. Salgo, MD: Three months. If they’re the same efficacy, why would anyone pick 2 weeks?
Steven Feldman, MD, PhD: That’s a good question. Their insurer might cover the 2-week drug.
Peter L. Salgo, MD: Because it’s cheaper?
Steven Feldman, MD, PhD: I don’t know that the 2-week drug is really any better for the arthritis, but there are more data saying that it’s effective for the arthritis and there’s approval for it. Another reason might be the every-2-week drug may have been in use in humans for 20 years, and patients may not want to take a new drug with unknown adverse effects when they could take something that’s tried and true. Another reason might be that Aunt Mildred, or somebody they know at church, did really well on the every-2-week drug, and they’re comfortable with it. Or, they saw Phil Mickelson advertising a particular drug on television, and that makes them feel good about that drug.
Peter L. Salgo, MD: But medically, is there a reason to go with 2-week versus 3-month medicine?
Joel Gelfand, MD, MSCE, FAAD: It depends on the patient. There are some patients interestingly enough who will have disease flare-ups in the weeks coming up to when they’re due for their shot. And that’s often a nuance between a variable chronic inflammatory disease. So some patients do better with more frequent dosing. Or it’s an every month drug but they really need that every month drug every 2 weeks.
Steven Feldman, MD, PhD: Some dermatologists have said, if something bad happens, if there’s an infection, the every-2-week drug will be out of your system, or the effects of it will be out of your system much quicker than if I put you on an every-3-month drug. And so I think when these miracle every-3-month drugs came out people were worried that the effect on the immune system, if something bad happens, won’t come out of your system. But having seen the safety profile, that’s not the case.
Peter L. Salgo, MD: I was going to ask you about that.