Economic Burden of Generalized Pustular Psoriasis


Mark G. Lebwohl, MD, and Maria Lopes, MD, MS, review the incidence and prevalence of generalized pustular psoriasis as well as direct and indirect costs associated with the disease.

Ryan Haumschild, PharmD, MS, MBA: I’d like to dive into that a little bit deeper as we talk about the rareness, maybe the incidents and prevalence. Dr Lebwohl, if you could talk about what the incidence and prevalence is, but really how does that relate to the age and presentation of these patients? And lastly, is it more prevalent in certain genders or ethnicities that we should be aware of?

Mark G. Lebwohl, MD: The prevalence in the United States is estimated to be anywhere from 1 in a million to almost 1 in 100,000. That would be high-end. That’s in the United States. In Japan, it is much higher. And we know the prevalence in Asian populations is much higher than it is in European or American populations. That’s first of all. It can occur at any age, children or [older] adults. I’ve seen it in a woman in her 80s. I have not seen it in an infant, although it’s well known, especially in people with the genetic predisposition. Interesting that you mention hospitalization and [the] ICU [intensive care unit]. There was a wonderful poster presented at a recent meeting by a dermatologist in France, and there they have a network of hospitals where the patients have all gotten together for specifically pustular psoriasis. And over a period of several years, they had, I believe, if I’m remembering correctly, 529 patients admitted to the various hospitals in this network for pustular psoriasis; a quarter of them ended up in the ICU. The death rate over that period of years was between 2% and 3%. And this, of course, was before we had spesolimab [Spevigo]. It just shows you how badly we need to have a new treatment. The other item you mentioned, Ryan, was you can’t wait for prior authorization to go through when you have a patient dying. And since the drug is approved in the United States, we already have this dilemma where the severity of the situation, forces the hospitals to figure out a way of getting this to our patients quickly. And that is a dilemma that we have to solve.

Ryan Haumschild, PharmD, MS, MBA: You bring up that burning platform that there has to be change, and not just change to make it easier on the practitioner, but changes for the patient and also education. Because I’m sure a lot of our payer colleagues recognize the value of early treatment. And I think as we talk about that, there’s the burden of disease and the burden of economics. And maybe Dr Lopes, we can get your thoughts on this. When we think about the economic burden of pustular psoriasis, can you talk maybe about some of the direct costs and indirect costs that you can see associated with the disease? And then maybe comment a little bit on the setting of care regarding the hospitalization. If we get early treatment and we can avoid maybe those ICUs or that length of stay, how do the payers think about that as well in that value proposition?

Maria Lopes, MD, MS: I think even if we can just keep the patient out of the hospital and out of the [emergency department (ED)], that’s a success in and of itself. But even if someone ends up going to the [ED] and perhaps even being admitted for a brief period of time, let’s say an observation, 23-hour observation, those rates are very different. The cost associated with that event, if you will, is going to be very different than if you’re in a hospital for 30 days and in ICU for 10 days and maybe have decompensation that goes beyond the post-acute setting, including organ failure. I heard heart failure. I heard kidney involvement, hypocalcemia, all these anemias, etc. Is there going to be repeated transfusions associated with supportive care needs and what organ damage has been done that you may not be able to reverse? Certainly, I think there’s a need for a better understanding of the disease and diagnosis. It’s fascinating when you think about where patients present and how we can create the opportunity to be able to treat the symptoms wherever the patient may be. Actually, a very good analogy to this is hereditary angioedema, where patients present and flare. Some treatments address the acute as well as prophylactic events, but you can’t wait for a prior authorization. You don’t have the luxury of time. Once the diagnosis is confirmed, it’s not only important for the hospital to carry the product and for the [ED] to carry the product that’s needed so that there’s a rapid reversal of the acute event but there’s also the need for the patients to know if they’re feeling or they’re presenting. Where can they go? What’s the nearest [ED] that actually carries that product to be able to be rapidly administered? And there is no prior authorization at that point? Their supply, the patients are directed to go, could even be an urgent center or an infusion center in their area because time is of the essence. This presents some opportunities; I think so that we can collectively work together. One is, again, the thought leaders that help us understand the nature of the disease, how often this presents, and establishing the appropriate diagnosis and then a lot of education for patients as well. I don’t know how easy it is for them to recognize even in the absence of pustules that something is going to be happening because the higher the cost, the more certainty a payer’s going to want to know that indeed there’s an event about to happen that we can have a response or an intervention that’s going to lead to a better outcome.

Ryan Haumschild, PharmD, MS, MBA: You hit on some great points. And one is the total cost of care algorithm. Many times we need to look at taking care of the patient by reducing hospitalization, we free up those beds. And by keeping them out of the hospital and by having an effective treatment early on, we reduce that length of stay. When we look at it through the payer lens, I think there is a total cost of care value proposition outside of just the acquisition cost of the drug, but the timeliness reduces the progression of the disease. And I think that’s exciting.

Transcript edited for clarity.

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