A Personalized Approach to Disease Management in Psoriasis - Episode 4
Bhavesh Shah, PharmD, and Mark Lebwohl, MD, explain the difficulties of patient adherence to psoriasis treatments.
[Editor’s note: In this Peer Exchange video and related transcript that ran on AJMC.com, Mark Lebwohl, MD, dermatologist at Mount Sinai, stated that “certolizumab pegol, which has a formulation that has to be diluted in the office, can't be given at home.”
Please note that certolizumab pegol is available in 2 formulations: lyophilized powder for in-office injection and pre-filled syringe for at-home injection.]
Ryan Haumschild, PharmD, MS, MBA: Dr Shah, speaking of quality of life, you being part of a payer arm within an IDN [integrated delivery network], what is that impacting? Dr Lebwohl talked about this. Absenteeism. I mean, when you're employing your own- When you're insuring your own employees and they're out of work, especially now in this post–COVID-19 environment, I mean, that's really difficult because you have to work at travelers, there might be a higher cost in terms of salary and really kind of impacts things even greater than just that one patient. Thus, I don't know if you can weigh in on some of these unique considerations associated with primary disease of plaque psoriasis related to some of the key considerations that Dr Lebwohl brought up.
Bhavesh Shah, PharmD: I think it really brings to light in terms of the indirect costs, from a payer's perspective, that really kind of needs to be highlighted. The University of Colorado did this economic evaluation, and they had identified that there was this $10 billion, or $30 billion in indirect costs, which was literally due to loss in productivity due to missing work, sick leave, unemployment. Thus, I think you add up all of these factors that are impacting quality of life. You can kind of see the downstream impact of that total cost of care that you're having on the health system and health plan. Hence, I think we definitely need to look at that from a value perspective in terms of how this disease can really impact the quality of life and what is the downstream impact of that, where you have patients who are losing productivity and missing work and having sick leave and unemployment, how is that really driving our cost to be unfavorable indirectly, but because of the disease?
Mark Lebwohl, MD: I wanted to actually raise the discussion that you started earlier on adherence, because to me, that is such an enormous problem in all dermatologic disease, but particularly in psoriasis. We have a number of drugs now that are given only 4 times a year, every three months. And they, in my experience, profoundly increase adherence. The other element here is that some of the drugs, and it changed recently, but some of them, they were covered by the patient's medical benefit if they were administered in the office or in the hospital. Patients had their appointments made and the doctor making the appointment kept track of how often they came back. Thus, it dramatically improved adherence. When we give it to patients to use at home, it becomes part of their pharmacy benefit. They sometimes will have a large co-pay. For commercial insurers, pharmaceutical companies have actually been excellent about covering that co-pay. They will often write off the balance that patients have to pay because the drugs are so expensive. It's often unrealistic to expect patients to have an annual co-pay of $10,000 or $15,000 a year. With Medicare, they can't do that. Medicare patients can only have the drug fully covered if it is part of their medical benefit and administered in the office. Until a few months ago, the CMS [Centers for Medicare and Medicaid Services] had determined that 3 of the drugs that are given every 2 or 3 months—ustekinumab, guselkumab, and risankizumab. Until recently, those were often administered in the office so that patients wouldn't have to pay for them. These were added to the self-administered drug list, so now they are treated as a pharmacy benefit that are given at home. I think, fortunately or unfortunately, tildrakizumab was not tested for in-home use, so it has to be given as a medical benefit in the office or in the hospital. The other 2 drugs that can be given as a medical benefit are infliximab, which is given intravenously usually in an infusion center. That is a medical benefit. Certolizumab pegol, which has a formulation that has to be diluted in the office, can't be given at home. If you prescribe any of those, the patients can get it as an office-administered product, which then is not associated with a co-pay. Those drugs actually dramatically improve adherence to therapy because the doctor is directly determining when they're given in the office or in the hospital. Therefore, the ability of a patient to depart from their protocol is reduced.
Bhavesh Shah, PharmD: I think this also impacts other diseases too. Risankizumab can be used also for IBD [irritable bowel syndrome]. And we essentially saw because of what I call the sad list because patients cannot afford their medication because Medicare essentially pushes it to pharmacy benefits. AS a result we’ve had to switch patients to ineffective therapies. They're on this long-term therapy and then they can't afford it. Now, we have to switch them to something that they can't afford, which is not as effective. Hence, it's really unfavorable what CMS is doing and putting these drugs on sad lists. I think that we have to have greater advocacy around stopping these types of changes that, as you said, it directly impacts adherence and it directly impacts patients who are optimized on therapy and having to switch to ineffective therapies.
This transcript has been edited for clarity.