COMMENTARY

Psoriasis Treatment With Biologics: 5 Things to Know

Caitlin G. Purvis; Steven R. Feldman, MD, PhD

Disclosures

June 14, 2021

2. When discussing potential for serious side effects, place statistics in the proper perspective.

The risk for serious infection associated with IL-17 and IL-12/23 inhibitors is something that clinicians need to address with patients prior to starting them on these medications. However, this discussion must be framed in the appropriate context of overall risk for infection in all patients with psoriasis. The risk for serious infection in patients taking an IL-17 or IL-12/23 inhibitor is close to that of patients with moderate to severe psoriasis who are not on these medications. IL-17 and IL-12/23 inhibitors have similar infection rates: 1.4 per 100 patient-years for IL-17 inhibitors and 0.83 per 100 patient-years for IL-12/23 inhibitors. According to the Psoriasis Longitudinal Assessment and Registry (PSOLAR), the rate of serious infections in these biologics does not appear to be higher than that seen in patients not on systemic treatments (1.05 per 100 patient-years), although an increased rate of candidiasis and occasional cases of inflammatory bowel disease have been reported with IL-17 inhibitors.

When discussing with patients the risk for serious infection with IL-17 or IL-12/23 inhibitors, it is important to present information in the appropriate context to provide reassurance and encourage adherence. For many patients, for example, it is unnerving to learn that "1 in 100" patients experience a serious infection; they may understandably fixate on the potential of being the one patient who develops a serious infection. Instead, using a positive framing technique to restate and communicate adverse event frequency may reassure patients and increase their willingness to follow the treatment plan. For example, explaining to a patient that 99 out of 100 patients receiving biologics do not develop a serious infection is mathematically identical to "one in 100 patients" but more reassuring.

3. Consider prescribing office-administered medications as first-line treatment for Medicare patients without Part D coverage.

Despite the introduction of novel therapies, some patients with moderate to severe psoriasis remain undertreated or untreated. Cost of and access to these drugs may be the underlying issue for some of these patients. In regard to patients on Medicare, most biologics are typically covered under Part D plans, which not all patients have. However, biologics that are approved only for administration by a healthcare provider may be covered under Medicare Part B. For example, tildrakizumab (subcutaneous injection) is assured coverage under Medicare Part B. Infliximab (intravenous infusion) may be covered by Part B as well. These drugs may therefore be accessible to patients who would not otherwise be eligible.

In addition to coverage benefits, data from the reSURFACE 1 and reSURFACE 2 phase 3 trials show increased efficacy of tildrakizumab when it is administered early in the disease course. Patients who started treatment with tildrakizumab less than 5 years after beginning to experience symptoms of psoriasis tended to show better results: 81.2% of patients achieved 75% improvement in the Psoriasis Area and Severity Index (PASI 75) with tildrakizumab 100 mg at 28 weeks when it was started within 5 years of disease onset vs 72.6% of patients who achieved a PASI 75 when treatment was started 10 years after disease onset. These data are not based on randomization to early vs late treatment, so various biases may account for the findings.

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