Roundtable discussion: Biologics in plaque psoriasis
Transcript: An open discussion
Professor Luis Puig, Professor Matteo Megna and Professor Matthias Augustin
Roundtable recorded Apr 2024. All transcripts are created from roundable footage and directly reflect the content of the roundtable at the time. The content is that of the speakers and is not adjusted by Medthority.
Let's go with one question here, it's about, are there specific considerations or protocols for transitioning patients from conventional systemic therapies to biologics, or particularly in terms of timing, monitoring, and potential care management? Do you have a limited time when the patient is starting to fail, of course, when an adverse event appears that we should switch or do whatever, but about failure, do you wait a lot in terms of switching or modifying the treatment? When a patient comes into my office and shows a failure to a non-biologic drug, I immediately start with the biologic, if it's indicated. So I don't leave any waiting time or wash out. Me too, no delay, no delay anymore. Sometimes, increasing the dose, doing a re-induction, might be helpful if you don't want to use one given biologic. This happens, especially in patients with secukinumab or ustekinumab.
Now and then, some patients might present a bit of a flare, which might be due to any many causes, infections or stress, whatever. And sometimes just adjusting the dose might prevent you from, let's say, burning one drug. Even in some cases, you can get back, I don't know if that's your experience, to a drug which has been previously switched off by the patient. Is that your case? How often do you feel that in some occasions you're getting back to one drug, which was eventually earlier withdrawn? Do you feel this happen in your practise? Less frequent than the past because- Okay. We have more drugs- Yeah, yeah. To just make an intra class or a- Yeah, but no, I don't expect newer biologics to appear in the foreseeable future.
So we'll be having more and more of these situations. Yes. Well, actually Luis, single patients are through all drugs in the meantime for different reasons, and then we have a normal choice then to restart with maybe the best experienced drug, so- Mm-hmm, exactly. Yeah. Agree. And when we get to palmoplantar pustular psoriasis, likely that's even more like marriage, we don't have any hint or clear as to what should we start. Yeah. Mm-hmm. There's one question here about what is your choice to treat plaque psoriasis affecting 20% of the body? I would say 20% of the body is not an issue. The problem, the issue is about three, 4%. Any patient with more than four hand prints is a patient who requires systemic treatment, at least in my experience.
I'm very bad for, as regards to treating myself with topicals. So I would say the problem is about 5%, not 20%. Yeah. Yes. As we see previously, we need to study different factors, not only like the BSA, to choose the correct drugs. Yeah, so I think that there's no question that this requires systemic treatment. Maybe it was sneaky presenting, but what is the choice among the systemics? And 20% of the body alone is not really driving the way to a single treatment choice. We have several options. Even with 20%, we may use a non-biologic drug if it's not very severe lesions. And so, more information is needed. But surely, systemic treatment is indicated. You said before that nobody of us do some kind of wash out when switching, but what about in surgery? Perhaps you did some exceptions of some dirty surgeries, which usually are not planned. Do you do anything special depending on the biologic, as regards withdrawal or lengthening the intervals, before or after some surgery? What's your approach, Matteo? Less than the past. Okay. Like if there is a programme at the surgery, I will just recall the topic on the half life of biologics and just to discontinue. Mmm. Like to have the life before the drug, but I'm not doing, like in the past for minor surgery or intervention, and so on. Now it's not my concern in real practise, with respect to the past. I don't know your experience. Actually, if it comes to the modern generation biologics, IL-17, IL-23 blockers, we mostly keep them. And the surgeons are even more in favour of having good control of the skin inflammation.
Yeah. This also what needs to be considered. There's obviously less complications with this when there's good coverage by the biologics, but it may be different in the non-biologic group. Of course. And what about your management of psoriatic arthritis? Are you managing them or are you referring all those patients? Is the waiting list for referral long? How do you take that? Yes, the waiting, in Italy, the waiting list is not so less. Yeah, actually we have the same situation. On average, about six months waiting time. And years back, the rheumatologist wanted us to wait so long and we said, we can't wait if there's active arthritis. And now with the drugs that we use for plaque-type psoriasis, which are also very effective in arthritis, the problem is mostly solved. So we just keep referrals to the rheumatologists for very unclear cases and otherwise do diagnostic workup ourselves with ultrasound, but otherwise a radiologist.
There's one question here about if the economy standard of a country affects the prognosis of psoriasis or the management. I would say not just the economy standard, even the educational level of a given patient might affect their response, or even, the super responders are always highly more educated. There's evidence in that respect. What's your take in that? And we're talking, we might talk, on one hand, on countries in the Western world, we might also talk on some countries with perhaps more limited resources. Maybe I comment on this being also a health economist, because I agree with what you said, Luis, and in fact, even within a country, we see that those groups who do not show good health behaviour provide higher risks in terms of obesity, consuming alcohol, drugs, whatever. And so, the risk for world psoriasis exists depending on, yeah, the socioeconomic status within the country, and in many countries, poorer countries, this adds to the less of access to drugs and to health. Yeah, I agree. Even within a given country across regions perhaps, also the access and the, even it might be that in some poorer regions, there is easier access. And so, there are many incongruencies in that respect. It's quite peculiar. So we should be thinking not on country terms, but also sometimes on region, zip code, or hospital terms regarding payers.
What do you, what's your take on early treatment of psoriasis? How do you recognise early stages of psoriasis? Or how, what's your approach to treating early? As differently from the past, we are now also in the referral centre, like University of Naples. We are seeing people with lower psoriasis duration, respect to the past, where we've seen just cases with a 10, 15 year of severe psoriasis history. So now, we are treating earlier the patient try to modify the natural course of the disease. And why not try also to prevent the comorbidities, such as psoriatic arthritis or cardio metabolic comorbidities. Now, we are trying, yes, to treat before and also to start before systemic or biologic treatment, respect to the past. I totally agree with this question. Yeah. Yes. No, there's one comment here about the use of biosimilars. I would say that the newer innovators are better, but biosimilars are more efficient. So it depends on the differences in price also. But again, in most cases, we are driven by efficiency. So biosimilars have a great role even in improving the access. And I, we are getting close to the end. Perhaps I would like to ask you to give one final comment.
Perhaps Professor Augustin will give one, just one comment, overall summary. Yes. Well, first of all, thank you for having this round and thank you to the audience to listen. I think we're doing wise when we combine real-world evidence with the RCT data, it's continuous education and learning. Every month, there's new articles that need to be digested and known. And this is why these rounds are great. Thank you. Thank you. Matteo? Thank you. I, well, I was very happy to participate in this webinar. We see like how is important real-life data and how are numerous difficulties. So why not this can be the starting point to perform multi-country, multinational, Europe, real-life registry in order to obtain more good quality evidence to help our patients in a better evidence-based way. Again, thank you very much. It's my time now to thank my colleagues, Professor Matteo Megna, Professor Matthias Augustin, and also especially all the attendees, everyone who has been here watching this webinar.
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