A Personalized Approach to Disease Management in Psoriasis - Episode 6
Bhavesh Shah, PharmD, and Mark Lebwohl, MD, elaborate on treatment effectiveness in patients with both psoriasis and metabolic syndrome.
Ryan Haumschild, PharmD, MS, MBA: I’m going to move on to the last question in this section. Bhavesh, I’m going to turn it onto you. The question for you is, we’re hearing a ton about metabolic syndrome. It’s environmentally controlled, there’s some genetics to it, but how effective are our standard treatment options in psoriasis in general, for patients who have psoriasis and metabolic syndrome? Because that’s a unique patient population that’s growing, that they’re predisposed to having metabolic syndrome. How do we focus in on that? Especially, I think of this in diversity, equity, and inclusion, as we want to think of patients with psoriasis as a whole, but how do we think of those more difficult to treat patients where, like Dr Lebwohl or Groves have mentioned and talked to them about lifestyle changes, yet they don’t see those changes actually occurring. But how do we still provide better control of psoriasis? And how do you think the standard treatments perform in that environment?
Bhavesh Shah, PharmD: I think you bring up a great point in terms of diversity and inclusion. I think Dr Groves had mentioned in terms of how these patients are not getting the access that they need sometimes because of their obesity. I think there’s probably a disconnect between the providers who are treating them for psoriasis and then also trying to manage all of the obesity and the metabolic syndrome comorbidities that they will develop essentially. I feel like there needs to be more education around this. I put my population health hat on, and our focus is managing diabetes, managing hypertension, managing hyperlipidemia, but we’re not helping those patients who also have psoriasis and optimizing those treatments there. Thus, I do think there’s definitely a need for more visibility on which treatments should we be using in this patient population that can help solve the equation of psoriasis and metabolic syndrome. From my understanding, I don’t think children are exempt from this either, they actually have the same type of issues that adults have. Thus, I feel like there’s even a bigger scope beyond the adults. I guess in terms of the biologics, I’ll kick it off to Dr Lebwohl, and Dr Groves in terms of talking about which ones are more effective in this type of disease.
Robert Groves, MD: I know when to defer. Dr Lebwohl, it’s all you here.
Mark Lebwohl, MD: I will say the features of the metabolic syndrome that were eloquently described by Dr Groves are all risk factors of cardiovascular disease: obesity, hyperlipidemia, hypertension, insulin resistance, diabetes. We want to get rid of those. We learned from the TNF [tumor necrosis factor] blockers, which by the way, are not that effective for psoriasis. I actually don’t use it very often anymore because they were associated with boxed warnings, and they just didn’t work as well as our new drugs. But we learned from huge registries that the rate of heart attacks in patients treated with TNF blockers was cut almost in half. In fact, in almost every registry, they’re cut in half. Thus, it turns out that reducing the inflammation associated with psoriasis reduces atherosclerotic vascular disease and heart attacks.
Some data are emerging now with the IL-17 [interleukin-17] blockers that were introduced next, showing reductions in lipid-rich necrotic core, showing reductions in atherosclerotic plaque. We hope that will eventuate in a reduction in heart attacks, similar or even greater than what was found with the TNF blockers. My expectation would be that any drug that works well for psoriasis and thereby reduces those inflammatory cytokines that contribute to heart attack, will ultimately prolong the lives of our patients by eliminating the No. 1 one cause of death, which is heart attack. We’re hopeful that that will happen. The drugs, the IL-23 blockers and the IL-17 blockers, haven’t been around long enough to definitively demonstrate that. But there are registries like CorEvitas that are following now 15,000 patients treated with the different biologic therapies, and that appears to be what they’re showing.
There was a registration with ustekinumab and the TNF blockers available at that time, called PSOLAR [Psoriasis Longitudinal Assessment and Registry]. It does look like from that registry that we were seeing reductions in heart attacks. Hopefully we’ll see that even more with the new, more effective drugs.
In terms of impact of the different drugs on psoriasis, even in the setting of obesity, which makes the TNF blockers work less well, even in that setting, we are seeing that the IL-17 blockers work pretty well, although some of them are a little less effective. That’s primarily secukinumab, while it’s a little less effective, it’s still very effective. Ixekizumab is a tiny bit less effective, but still very effective. Brodalumab is very effective, even in the setting of obesity. The IL-23 blockers in patients who are obese seem to work extremely well. That is important not only for their psoriasis, but for all of the other manifestations of the disease, primarily the cardiovascular manifestations.
This transcript has been edited for clarity.