A Personalized Approach to Disease Management in Psoriasis - Episode 12
Dr Lebwohl explains how he can recognize who will respond early to psoriasis treatments and who won’t respond at all.
Ryan Haumschild, PharmD, MS, MBA: You bring up some great points between some patients who are early responders or responders and patients who are nonresponders. As we look at treating these patients, Dr Lebwohl, how do you consider a patient and identify a nonresponder earlier, and how can those data be used in real-world evidence to change the treatment for that specific patient type earlier, so they respond earlier to therapy and they don’t have that same kind of lagging behind their other cohorts of patients? In other words, how do you leverage real-world evidence and EMR [electronic medical record] data to identify nonresponders and potentially change treatment pathways for them? Is that something you’re looking at? Do you see that as the future of treatment in this patient population?
Mark Lebwohl, MD: I do think that it plays a very important role in having a set decision point, when do we change, when do we know a drug’s not going to work? And often, the time that has been picked is 4 weeks. But for other drugs, it’s 3 or 4 months. A drug that’s fast, like ixekizumab actually did a study where they showed if you haven’t achieved a 50% reduction in PASI [Psoriasis Area and Severity Index] score by week 4, there’s a reasonable chance that you won’t ever achieve the end point you’re looking for by week 12 or 16. Week 4 is an important time point for certain drugs. The IL-23 [interleukin-23] blockers on average are slower. I can tell you that I’ve had patients, a physician, who came in saying, “Well, nothing works. I’ve tried every biologic, nothing works.” The IL-23 blockers had come out, and I encouraged her, and I warned her up front, that these are slow. Now, some of the IL-23 blockers, including tildrakizumab, have looked also at week 4 as an end point and said, if I remember the data correctly, if you achieved at least a 38% improvement in PASI score by week 4, there was a good chance that you would ultimately achieve a PASI 75, which is a very good end point, a very good result. I think I remember those numbers correctly; I may be mistaken. Tildrakizumab is a much slower treatment than most of the other treatments we have. But as I said, it peaks at 7 months.
Now, I had another of the IL-23 blockers that we used for this physician. And I told her, “Look, you have to wait at least until week 16.” And sure enough, she came back at week 4 and she said, “This is not working.” She came back at week 12, “This is not working.” At week 16, she cleared completely. I think there are going to be different patients who have different outcomes. There are a number of companies that are actually looking at identifying genetic markers to predict which [patient] is going to respond to which treatment at which point. There’s a company called Madera that’s looking at this. There are actually several genetics companies in the dermatology space now that have been very successful, for example, at predicting which melanoma is going to spread. They have the technology to help us find the genetic markers that tell us, “OK, if a patient has this genetic profile, you might want to use a different drug because they are less likely to respond to various drugs.”
Thus, hopefully one day we will have that kind of personalized medicine approach. But right now, we don’t have it. And right now, we treat patients with the drug we think is best for them based on their overall picture. Then at a certain point, you have to make a decision, are they responding or not? For certain drugs, it might be 4 weeks. I think for more drugs, it’s week 12 or week 16.
Ryan Haumschild, PharmD, MS, MBA: That was a great story you shared about that colleague, and such a difference from week 4 to week 17, and to see kind of the “I told you so” moment there as you consider them uniquely.
This transcript has been edited for clarity.