Psoriasis and your Patients
These days, it seems that most of us can’t avoid seeing a TV ad for a psoriasis medication when watching our favorite shows. Most of these ads seem to promise “clear to near-clear skin” using these medications. Unfortunately, this promise follows many horrible side effects that no reasonable person would consider when selecting a medicine to treat themselves or a loved one who has psoriasis. So, what’s the real “low down” on the safety of biologic therapy in psoriasis, especially during the COVID-19 pandemic? What should you tell your patients?
The bottom line is that based on phase three clinical trial data and real-world experience, the newer biologic agents for psoriasis appear to be very safe. The older tumor necrosis factor-alpha agonist (TNF-α) agents (Enbrel, Humira, Remicade, and Cimzia) effectively provide significant skin clearance. Still, they carry risks of infection, malignancy, new-onset or worsening CHF, and demyelinating conditions. These risks tend to be below, but they are still a legitimate concern. The next-generation biologic agent, an interleukin 12-23 (IL-12/23) agonist (Stelara), provides a safer profile with a lower risk of infection and even better skin clearance than the TNF- α agents. The IL-17 agonists (Cosentyx, Talz, and Siliq) provide adequate skin clearance. Still, they carry a risk of new-onset or worsening gastrointestinal (GI) conditions, such as irritable bowel disease (IBD) or Chron’s disease, as well as increased risk of fungal infections. One agent, Siliq, also carries a warning of an associated increase in depression and suicidal ideation and requires enrollment in an online, national monitoring program. However, the risks associated with the IL-17 inhibitors are also low, and many patients continue to have excellent skin improvement with the long-term use of these drugs. The newest biologics are the IL-23 inhibitors (Ilumya, Skyrizi, Tremfya). These agents have demonstrated some of the highest levels of skin clearance with excellent safety profiles. There doesn’t appear to be a higher risk of infection, mood changes, malignancy, or GI side effects in clinical trials compared to placebo. Because these are the newest agents (approved within the last three years), more extended, “real world” data will help confirm these agents’ good safety profiles. In addition, for most patients, it’s perfectly safe for patients to start or continue to take these biologic agents without increasing the risk of contracting the COVID-19 virus.
What does this mean for you, as a practitioner? When assessing your psoriasis patients, it is essential to obtain a thorough medical history, specifically asking about a history of infections, malignancies, depression and suicidality, and GI conditions. It enables you to have a fair and honest discussion with your patients about the myriad of agents available for the treatment of psoriasis and their safety profiles. Do not let your (or your patient’s) concerns about perceived side effects prevent you from appropriately treating your patient’s moderate to severe psoriasis. Psoriasis not only affects the skin but nearly every organ in the body. Patients with psoriasis are at higher risk of developing psoriatic arthritis (leading to permanent joint damage and dysfunction), metabolic syndrome, cardiovascular disease (including increased risk of MI and CVA), non-alcoholic liver disease, chronic renal disease, and depression and anxiety. By selecting the correct psoriasis medication and appropriate monitoring, psoriasis patients can achieve clear skin safely, prevent associated comorbidities and live healthy and happy lives.
See Lakshi Aldredge speak at a 2022 Skin, Bones, Hearts & Private Parts CME Conference. Click here to find out where you can see her live and in-person!